Reliance Two Wheeler Package Policy - Endorsement Schedule

Corporate Office/Policy Issuing Office Policy Servicing Branch Office:

Reliance Centre, South Wing, 4th Floor, Reliance General Insurance Co. Ltd,
Off.Western Express Highway, 3rd Floor, Star Trek Building, Opp. ABS Tower Old Padra Road, Vadodara VADODARA
Santacruz (East), Mumbai - 400 055,India.
VADODARA GUJARAT
390007

Name of the Insured Mr. UPADHYAY KIRTANKUMAR MAHENDRAPRASAD

Correspondence Address of the Insured BRAHMAN FALIYU SHAMNA SHAMNA TA –

LUNAWADA DI-MAHISAGAR GUJARAT -
389230
India
Mobile No: 9974441335

Policy No: 775121823120000078 Policy Period:From 25/05/2018 to 24/05/2019

Endorsement No. 21008 TAX Invoice No & Date : E051718122528 & 17/05/2018
GSTIN/UIN of Insured :
Endorsement Effective Date: 29/05/2018
Type of Endorsement: Nil
Vehicle Make Vehicle Model Engine No./Chassis No. Registration Number

HONDA ACTIVA 5G 7084213 / 084165 NEW

Not withstanding anything to the contrary contained in the policy, it is hereby declared and agreed that Vehicle is name miss to mr.,. . All other terms and conditions of the policy remain unchanged.
Subject otherwise to terms, exclusions, conditions, limitations and warranties of the Policy.

Premium Summary

Premium Breakup Amount(Rs.)

Net Premium 0.00

CGST @ 9.00 % of Net Premium 0.00

SGST @ 9.00 % of Net Premium 0.00
Terrorism Premium 0.00

Total Premium 0.00

GSTIN : 24AABCR6747B1ZM HSN : 9971

Description of Services : Motor vehicle insurance services

Note: In the event of dishonor of the cheque, this endorsement automatically stands cancelled from inception, irrespective of whether a separate communication is sent or not.

This document shall be treated as a Tax Invoice as per Rule 9(2) of the Goods and Services Tax Invoice Rules In witness whereof this Policy has been signed at Mumbai on
policy tax invoice date in lieu of Proposal/Covernote No. as mentioned in the policy. In case of any assistance with claims, please contact us on 1800 3009 (toll free) or email us
at rgicl.services@relianceada.com.

In case of renewal, the benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change.

Grievance Clause: For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 1800 3009 or may write an email
at rgicl.services@relianceada.com. In case the insured is not satisfied with the response of the office, insured may contact the Nodal Grievance Officer of the Company at
rgicl.grievances@relianceada.com. In the event of unsatisfactory response from the Nodal Grievance Officer, insured may email to Head Grievance Officer at
rgicl.headgrievances@relianceada.com. In the event of unsatisfactory response from the Head Grievance Officer, he/she may, subject to vested jurisdiction, approach the
Insurance Ombudsman for the redressal of grievance. Details of Insurance Ombudsman are available at IRDAI website www.irdai.gov.in or on company website
www.reliancegeneral.co.in or on www.gbic.co.in. The insured may also contact the following office of the Insurance Ombudsman within whose territorial jurisdiction the branch
or office of the company is located :Office of the Insurance Ombudsman,Jeevan Prakash Building,6th floor,Tilak Marg,Relief Road,Ahmedabad – 380 001. Tel.: 079 -
25501201/02/05/06 Email: bimalokpal.ahmedabad@gbic.co.in

Intermediary Name & Code 18P00928 / PRAFUL VALLABHBHAI PATEL

Intermediary Contact No: 9687735708 / 9687735708

Authorized Signatory

Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2008 Certified Company
Registered Office: H Block, 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai - 400710.
Corporate Office:Reliance Centre, South Wing, 4th Floor, Off Western Express Highway, Santacruz (East), Mumbai - 400 055.
Corporate Identity No.U66603MH2000PLC128300. UIN No.:
RGI/UW/CO/2312 /PE/VER. 1.0/310118
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company
Limited under License.