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1. visit [Link] Digitally signed by

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3. Scan the QR code on this policy and be Date: 2018.09.10
assured that you have an original policy
[Link]
SID091018035289

"A" Policy for Act Liability Insurance (Passengers Carrying 4W<6) Policy- Schedule
Policy Number : 920221823530002030 Ma Proposal/Covernote No : R10091818606
TELANGANA - Hyderabad Central

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Insured's Name : Period of Insurance :
[Link] GANGADHAR 1 10- From 00:01 Hrs on 11-Sep-2018 to 23:59 Hrs of 10-Sep-2019
0 920 235

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Communication Address & Place of Supply : Policy Servicing Branch :
1-11-110/64/1,TATA CHARI COLONY,SHYAM LAL BULDING BEGUMPET, RELIANCE CENTRE, SOUTH WING, 4TH FLOOR, OFF. WESTERN
0 SECUNDERABAD, HYDERABAD, TELANGANA, EXPRESS HIGHWAY, SANTACRUZ (EAST), MUMBAI

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INDIA,500016 MAHARASHTRA 400055
FINAN

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Mobile No : 7799266772 Tax Invoice No. & Date : R10091818606 & 10/09/2018
Email-ID : manthatigangadhar@[Link] GSTIN/UIN of the Insured :

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Nominee Name : HYMAVATHI IGST

Insured Vehicle Details

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Registration No. TS09UA3610 Mfg. Month & Year JUL-2015
Make / Model TATA / INDICA EV2 / LS CC / HP 1396

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Engine No./Chassis No. 1.4CRAIL08GUYW04084/MAT600435FTG11045 LCC Including Driver 5
Type of Body NA Total Premium ` 12764.00
TELANGANA - Hyderabad Central Khairatabad
RTO Location Total IDV ` NA
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Vehicle Category Vehicle Usage Type
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Vehicle Usage Sub Type
Hypothecation/Lease NA
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Premium Summary
Own Damage Amount (`) Liability Amount (`)
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Basic OD 0.00 Basic Liability (TPPD 1) 0 10667.00

TOTAL OWN DAMAGE PREMIUM 1 0.00 Total Basic Liability Premium 1 10667.00
PA Benefits - Section III 1
100.00
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Compulsory PA cover to Owner Driver 0

Total PA Premium 1 100.00
Legal Liability to paid driver and/or Conductor 0
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and/or cleaner 0 50.00

TOTAL LIABILITY PREMIUM 1 10817.00
TOTAL PACKAGE PREMIUM (Sec I + II + III) 1 10817.00
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IGST (@18.00 %) 0 1947.00

TOTAL PREMIUM PAYABLE (`) 12764.00

0 GSTIN :27AABCR6747B1ZG, HSN :9971, Subject to [Link]. IMT ,40

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Description of services : Motor vehicle insurance services 0. 0.0

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Nominee Details

PA Owner Driver Nominee Name Age Relationship with Owner Driver Appointee name
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1 HYMAVATHI 27 Spouse
12764.00
Limits of liability : (a) Under Section II (1)(i) of the Policy-Death of or bodily injury to any person so far as it is necessary to meet the
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requirements of the Motor Vehicle11-Sep-2018

Act, 1988. (b) Under Section II (1)(ii) of the Policy-Damage to property other than
property belonging to the insured or held in trust or in the custody or control of the insured up to the limits specified- (TPPD
10-Sep-2019
1 Sum Insured - ` 7,50,000/-, TPPD 2 Sum Insured - ` 6000 /-).

Limitations as to use : The policy covers the use only under a permit within the meaning of Motor Vehicle Act, 1988 or such a carriage falling
under sub-section (3) of Sec 66 of the Motor Vehicle Act, [Link] Policy covers use for any purpose other than: (a)
Organized
10817.00racing (b) Pace making (c) Speed testing (d) Reliability trials (e) Use whilst drawing a trailer except the towing
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(other than for reward) of any one disabled mechanically propelled vehicle.

Persons/Classes of persons Any person including insured: Provided that a person driving holds a valid driving license at the time of the accident and is
: not disqualified from holding or obtaining such a license. Provided that the person holding a valid learner’s license may
entitled to drive
drive the vehicle when not used for the transport of passengers at the time of the accident and that such a person satisfies
the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.

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 DIRECT/Direct

Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID

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"It is hereby declared and agreed that all pre-existing damages to the vehicle having occurred prior to the commencement of cover are excluded from the scope of
the policy".
The policy wording with detailed terms, conditions and exclusions are available on our website [Link]
Consolidated Stamp duty Paid vide Letter of Authorisation No. CSD/89/2018/2910-11/18 dated 25th July 2018**Not Applicable for the State of J&K

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This document shall be trated as a Tax Invoice as per Rule 9(2) of the Goods and Services Tax Invoice Rules
Statutory Provisions: IGST

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"As per Section 146 of the Motor Vehicle Act, 1988 it is Mandatory to have your vehicle insured against third party risk.
I/We hereby certify that the Policy to which the certificate relates as well as this certificate of insurance are issued in accordance with the provision of Chapter X and
Chapter XI of M.V. Act, 1988. Note: In the event of dishonor of cheque, this policy document automatically stands cancelled from inception irrespective of whether a
separate communication is sent or not.
Safeguard your transaction by paying your premium via crossed cheque/DD in favour of Reliance General Insurance Co. Ltd.

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The policy has been issued based on the information provided by you and the policy is not valid if any of the information provided is incorrect. Subject otherwise to the
terms, conditions and exclusions of the Reliance Passenger Carrying Vehicle Liability Policy. 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.
Updating Registration Number of vehicles within 15 days of policy inception is MANDATORY as per IRDA. Kindly provide the same to your Agent/Our Call

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centre/Policy issuing Branch (Applicable for policies booked without Registration No of vehicles).
IMPORTANT NOTICE: The insured is not indemnified if the vehicle is used or driven otherwise than in accordance with this Schedule. Any payment
made by the Company by reason of wider terms appearing in the Certificate in order to comply with the Motor Vehicle Act, 1988 is recoverable from the Insured. See
the clause headed 'AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY'. For legal interpretation, English version will hold good.

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In case of a 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 [Link]@[Link]. In case the insured is not satisfied with the response of the office, insured may contact the
Nodal Grievance Officer of the Company at [Link]@[Link]. In the event of unsatisfactory response from the Nodal
Grievance Officer, insured may email to Head Grievance Officer at [Link]@[Link]. In the event of unsatisfactory
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response from the Head Grievance Officer, he/she may, subject to vested jurisdiction, approach the Insurance Ombudsman for the redressal
of grievance. Details of the offices of the Insurance Ombudsman are available at IRDAI website [Link] or on company website
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[Link] or on [Link]. The insured may also contact the following office of the Insurance Ombudsman within whose
territorial jurisdiction the branch or office of the Company is [Link] of the Insurance Ombudsman,3rd Floor,Jeevan Seva Annexe,S. V.
Road,Santacruz (W), Mumbai - 400 054. Tel.: 022 - 26106552 / 26106960 Fax: 022 - 26106052 Email: [Link]@[Link] | Shri.
A. K. Sahoo Office of the Insurance Ombudsman,Jeevan Darshan Bldg.,3rd Floor,C.T.S. No.s. 195 to 198,N.C. Kelkar Road,Narayan Peth,
ura

Pune – 411 030. Tel.: 020-41312555 Email: [Link]@[Link]

Note: Kindly acknowledge the receipt of this policy. In case you find any variations against your proposal or any discrepancy in the policy, kindly contact us
In the unfortunate event of a claim, please call quoting your Policy No. on 1800 3009 (toll free) and register your claim immediately within 7days from the date of loss.
For Customer service, please call along with your Policy No. on 1800 3009 or visit [Link]
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In the absence of any communication from you within a period of 15 days of receipt of this letter, we will consider that the issued policy is in order and as per your
proposal.

Special Conditions : NA
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For Reliance General Insurance Co. Ltd.

SID0910180352
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Authorised Signatory
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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/Policy Issuing Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Identity No.U66603MH2000PLC128300. RGI/MCOM/CO/PCVTP/PS/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.
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 A Policy for Act Liability Insurance
(Commercial Vehicle-Liability Insurance Proposal Form)

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(The liability of the Company commences only when this proposal is accepted by the Company ans the premium is received.)
PCV GCV MISC D Trailer 0.0

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For Office Use Only

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Policy Number 920221823530002030 Date

Intermediary Details (To be filled in BLOCK LETTERS)

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Intermediary Name Direct Code Direct
Branch Name Corporate Office(Servicing) Code 9202
Sales Manager Name Hyd Telesales Code D9202231

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Proposer's/Owner Details (To be filled in BLOCK LETTERS)

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1. Proposer/Owner's Full Name Mr. Mrs. MANTHATI GANGADHAR
2. Address(where the Vehicle is normally kept)
Flat/Building 1-11-110/64/1,TATA CHARI COLONY Road/Street/Sector SHYAM LAL BULDING BEGUMPET

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Area City SECUNDERABAD,
Pincode 500016 State TELANGANA, Country India
Phone 06300528743 Mobile 7799266772
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Emergency Contact Blood Group
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Fax
Email manthatigangadhar@[Link]
3. Occupation / Business Others
Mr.
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4. Type of Cover Liability Only Policy

5. Period of Insurance From 11/09/2018 hrs on To 10/09/2019 hrs on

6. UID Aadhaar No. 7. Pan No.
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8. Do you have a GST Registration Number Yes No

If Yes, Please specify
9. Related Party Yes No
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10. Source of Funds Business Profession Salary Agricultural Income Savings Others
11. Monthly Income Upto ` 20,000 `20,001 to `50,000 `50,001 to `1,00,000 `1,00,001 and above
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Details of the Vehicle

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12. Registration Number TS09UA3610 13. Date of Registration 21-Aug-2015

14. Registering Authority & Location TELANGANA - Hyderabad Central Khairatabad
15. Year & Month of Manufacture JUL-2015 16. Engine Number 1.4CRAIL08GUYW0408

17. Chassis Number MAT600435FTG11045 18. Make of Vehicle TATA

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19. Type of Body/Model NA / INDICA EV2

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20. Gross Vehicle Weight(GVW) 21. Cubic Capacity 1396

22. [Link] carrying capacity ([Link] passengers )in case of Passenger Carrying Vehicles 4
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23. Seating capacity including Driver 5

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An ISO 90001:2008 Certified Company

IRDAI Registration No. 103. Reliance General Insurance Company Limited. Registered Office : H Block, 1st Floor, Dhirubhai Ambani Knowledge
City, Navi Mumbai - 400710. Corporate Ofiice: Reliance Centre, South Wing, 4 th Floor, Off. western Express Highway, Santacruz (East), Mumbai -
400055. Corporate Identity Number U66603MH2000PLC128300. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private
Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/MOT-02/PVT-CAR-PF/Ver.1.2/300117.

Page 3 Of 6
 Details of the Vehicle Type and Use

24. Whether the Vehicle is driven by Non-conventional Source of power ? 0.00 Yes No
If Yes, please give details Bi Fuel CNG LPG

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25. Whether the use of vehicle is limited to own premises ? Yes No
26. Whether the Commercial Vehicle is also used for private purpose(excluding use of hire or reward)? Yes No
27. Whether the Vehicle is used for Driving Tuitions ? Yes

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No

Liability Coverage

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28. Coverage for liability against Third Party Risks (Death or Bodily Injury) required in respect of:
i) Owner Driver Only Yes No
ii) Any person other than Paid Driver Yes No

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If 'Yes', give details of such other persons
a.
b.

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c.
Note:
1. Section 146 of Motor Vehicle Act-1988 makes it mandatory for the owner of the vehicle to ensure that he or any other person authorized by him to

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drive a vehicle in public place has insurance against third party risks. The explanation to the section 146 exempts the paid driver)

2. As per section 147(2)(a) the ability is 'as incurred' in case of death/bodily injury of athird party.

29. Do you wish to have statutory Third Party Property Damage (TPPD) liability of Rs. 6000/- only?
e Yes No
30. Legal liability to persons employed in connection with operation of the vehicle who are 'workmen'. Yes No
The liability of the employer under the Workmen's Compensation Act 1923 is covered under the
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Motor Vehicle Act 1988 750000.00
a. Drivers No. of persons:
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b. Employees (Workmen) No. of persons:

Note: The Motor Vehicle Act1988 under sec.147(1)(ii)(i) covers liability to employees who are workmen within the meaning of the Workmen's
Compensation Act 1923
Yes No
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31. The Policy provides additional Third Party Property Damage liability limits of Rs.1,00,000/- for
Two Wheelers and Rs.7,50,000/- for other classes of vehicles. Do you wish to cover the additional limit?
32. Do you wish to cover wider legal liability to employees who are 'workmen' ? Yes No
(This information is sought to cover in addition to liability under the Workmen's Compensation Act
1923, also liability under the Fatal Accidents Act 1855 and the Common Law)
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Note: The additional liability under common law and Fatal Accidents Act in respect of employees who
are workmen is covered under this endorsement
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33. Do you wish to cover wider legal liability to employees who are NOT 'workmen' ? Yes No
Note: The additional liability under common law and Fatal Accidents Act 1855 in respect of emplyees
who are NOT workmen is covered under this endorsement
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34. Personal Accidents Cover for Owner Driver is compulsary in the Liability Only Cover. Please give details of nomination :
Name of the Nominee Age Relationship Name of the Appointee Relationship of the Nominee

HYMAVATHI 27 Spouse
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Note :
i) Personal Accident Cover for Owner Driver is compulsary for sum Insured of ` 2,00,000/- for Private Cards
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ii) Complusary PA Cover to owner driver cannot be granted where a vehicle is owned by the company, a partnership firm or a similar
body corporate or where the owner-driver does not hold an effective driving license
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35. Do you wish to include Personal Accident Cover for Named persons ? Yes No
If 'Yes' , give name and Capital Sum Insured (CSI) opted for :

Name CSI Opted (`) Nominee Relationship

Note : The maximum CSI available per person is `2,00,000/- in case of Commercial Vehicles
36. Do you wish to include Personal Accident cover for Un-named Passengers / hirer / pillion passengers Yes No
(Two Wheelers ) ?

Page 4 Of 6
 If 'Yes', give number of persons and Capital Sum Insured (CSI) opted:
No. of persons CSI (per person):
Note : The maximum CSI available per person is Rs.2,00,000/- in case of Commercial Vehicles INDIA

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37. Do you wish the Geographical Area of the coverage by the policy to be extended to the following countries ?
Please tick relevant Bangladesh Bhutan Nepal Pakistan Sri Lanka Maldives

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Note : Presently the territory covered is geographical area of India. Extension of geographical area cover can be availed by the use of this endorsement

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Details of Previous History
38. Date of purchase of the vehicle by the Proposer:

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39. Whether the vehicle was new or second hand at the time of purchase New Second Hand
40. Will the vehicle be used exclusively for
i) Private, Social, Domestic, Pleasure & Professional Purpose? Yes No

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ii) Carriage of goods other than samples or personal language? Yes No
41. Is the vehicle is in good condition? Yes No

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If 'NO' please give details

42. Name of the previous insurer

43. Address of previous insurer

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Flat Building Road/Street/Sector
Area City
Pin Code State Country
Phone Mobile
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Email Fax
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44. Previous Policy Number
45. Period of Insurance From To
46. Claim loged during the preceding 3 years
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Year No. of claims Claim Amount (Rs.)

Driver Details
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47. Date of Birth of the Owner: Age

SID0910180352
48. Date of Birth of the Driver Age
49. Does the driver suffer from defective vision or hearing or any physical infirmity? Yes No
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If 'Yes', please give details of such infirmity

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50. Has the Driver ever been involved / convicted for causing any accident of loss ? Yes No
If 'Yes' , give details as under including the pending prosecutions :
Driver's Name
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Date of Accident Loss / Cost (`)

Circumstances of Accident / Loss :
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Details of Hire Purchase / Hypothecation / Lease

51. Please state if the vehicle is under Hire Purchase Lease Agreement Hypothecation Agreement FIN
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If so , give name and address of concerned party / parties.

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Full Name M/s

Address Pincode
( Note :Copies of [Link] , Permit & Fitness Certificate should be submitted along with the Proposal Form )
Payment Details
Cheque DD SID0910180352
Cheque or DD Amount /- Amount in words
Bank Name
Cheque/DD No. Cheque/DD Date

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 Proposer's Bank Details
52. Name of the Bank Account Holder Mr. Mrs. Ms.
53. Bank Account No. 54. Account: Saving Current

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55. Name of the Bank
56. Branch SID0910180352

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57. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)
58. IFSC Code (11 character code appearing on your cheque leaf)

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I understand that any refund due on the premium payment / any paymeant / claims to be directly credited to my a foresaid Bank Account.*
* As per IRDAI, its mandatory that all payments made to be insured are only through electromnic made

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AML Guidelines
I/We herby confirm that all premiums have been / will be paid from bonafide sources and no premium have been/ will be apid out of the proceeds of crime
related to any of the offence listed in Prevention of Money Laundering Act 2002. I understand that the company has the right to call for the documents to
establish source of [Link] insurance company has the right to cancel the insurance contract incase I am/have been found guilty by any competent court

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of law under any of the statues, directly/indirectly governing the prevention of Money Laundering in India.
SID0910180352
Nationality : Indian Non- Indian , If Non-Indian please specify the country

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Type of Organization: Corporations Government Non Government Organizations Society Trust Partnership
International Organization Cooperatives Section 25 Companies

Declaration

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I/We hereby declare that te statements made by me/us in this Proposal Form are true to the best of my/our knowledge and belief and I/We hereby agree
that, this declartion shall form the basis of the contract between me/us and RELIANCE General Insurance Company Limited . I/We also declare that , if any
additions or alterations are carried out after the submission of this proposal form, then the same would be conveyed to the insurers immediately. I/ We
hereby declare that the contents of the form and documents have been fully explained to me/us and that I/We have fully understood the significanceof the
proposed contract. I/We agree to accept a policy subject to the condition prescribed by the company. I/We declare that the rate of NCB stated above by
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me/us is correct and that no claim has arisen in the expiring policy (copy of the policy enclosed/) I/We further undertake that, if this declaration is found to bre
incorrect, all benefits under the policy in respect of section I of the policy will stand forfeited.I/We further understand and agree that RELIANCE General
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Insurance will seek confirmation of above stated details from my/our previous insurers. Pending receipt of necessary confirmation, I/We agree that, though
coverage under the policy will be available to me/us, RELIANCE General Insurance will be liable to release the payment towards any claims under section I
of the policy only after a confirmation in this regard is received,In the event this declaration is found to be incorrect, any and all coverage available under
section I of the policy from the date of commencement of the policy shall stand automatically forfeited. Further, any survey arranged/ allowed by RELIANCE
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General Insurance of the motor vehicle , pending confirmation of the declaration from my/our previous insurers , shall be without prejudice to any of the rights
and remedies available to RELIANCE General Insurance as contained herein and under the relevant laws and regulations. I/We acknowledge and agree
that, Pending receipt of confirmation of the declaration from my our previous insurers, the "cash-less repair facility" provided by RELIANCE General
Insurance shall stand suspended. I/We also shall endeavour to procure the renewal notice and pass on the same to RELIANCE General Insurance
immediately upon the receipt of such renewal notice. Mode of Payment: Secure your payment by cheque/DD favouring Reliance General Inurance CO. Ltd.
This policy shall be voidable at the option of the company in the event of mis-representation, mis-descriptionof non-disclosure of any material particulars by
Ins

the Poposer. Any person who knowingly and with intent to defraud thr Insurance Companyor other persons, files a proposalto insurance containing any false
information, or conceals for the purpose of misleading, information, information concerning any fact material thereto, commits a fraudulent act which will
render the policy voidable at the company's sole discretion and result in a denial of insurance benefits.
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I/We further agree and undertake not to receive from Reliance General Insurance Company Limited and any rebate other than that mentioned in the
published prospectus in accordance with the provisions Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015
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Place:
Signature of Proposer
Date:
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Prohibition of rebates - Section41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015

1. No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in
respect of any kind of risk relating to livesor properly in India, any rebate of the whole or part of the commission payableor any rebate of the premium
shown on the policy, nor shall any person taking out or renewing or continuing a policyaccept any rebate as may be allowed in accordance with the
published prospectuses or tables of the insurer
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[Link] person making default in complying with the provisions of this section shall be liablr for a penalty which may extend to ten lakh rupees.
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Note: Denial of "Third Party Liability Only Cover" by Insurer ,for reasons other than fraud/misrepresentation by Proposer , will entail Regulatory action.

IMPORTANT NOTICE
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1. In the event of a claim, please immediately call our 24 hour call centre only. Improper intimation or delay in intimating claim to call centre can lead to delay in
settlement/denial of claim.
2. For preferred cashless garage list please logon to our website or speak to customer care executive. RGICL cannot provide cashless claim settlement at garages other than
those in our network list*
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[Link] intimate us your mobile number and we shall keep you updated of the status of the claim by the way of SMS periodically. You can download our claim formand claim
procedure. Also view claim status on our website.
Insurance is the subject matter of solicitation *condition apply

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