SCHEDULE CUM CERTIFICATE ACT ONLY

INSURANCE POLICY- PRIVATE CAR

InsureMo
Liability Only Policy / Certificate No : POPMCAR00101751926

QR code for mobile download app: Alternate Policy No :

Policy Issue Date : 05/06/2025

Please scan the code to view the policy details
Customer ID :
Name : Mr RUPDA SUNILKUMAR JAGDISHCHANDRA Policy Servicing Branch :
Address : Svaminarayan Mandir Jetpur, Intermediary Name : PROBUS INSURANCE BROKER PVT LTD
Voravad,Rajkot Rajkot,
Gujarat Intermediary Code : 0046764
360370
Intermediary Contact No : +91-7710085785

Contact No : 7990491282 Period of Insurance TP : From:06/06/2025 [Link]

To:05/06/2026 [Link]
Email Id : shivinsurance3@[Link]
Period of Insurance PA to : From:06/06/2025 [Link]
Owner Driver TO:05/06/2026 [Link]

RUP

Dear [Link] SUNILKUMAR JAGDISHCHANDRA,

Welcome to the SBI General Family. With SBI Act Only Insurance Policy - Private Car, you can be in control & enjoy the journey no matter what
roadblocks life throws at you.

ABOUT YOUR POLICY

Policy/ Policy Issue Period of

certificate no Date Insurance TP

POPMCAR00101751926 From:06/06/2025 [Link]

05/06/2025 To:05/06/2026 [Link]

Period of Insurance Policy

PA Cover to Owner Driver Type Geographical Area

: From:06/06/2025 [Link] Liability Only India

TO:05/06/2026 [Link]

SBI General Insurance and SBI are separate legal entities and SBI is working as Corporate Agent of the company for sourcing of insurance products

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]
 727.38
0.0 0.0
0.0 0.0 0.0

ABOUT YOUR VEHICLE

Vehicle Make Registration Manufacturing Cubic Capacity /

Model & Variant Number Year Kilo Watt

Hyundai,Xcent & VTVT SX 1197

BSIV GJ05RJ8165 2017

Engine & Chassis Seating RTO

Fuel Number Capacity Location

G4LAHM532420 &
Petrol MALA841CLHM272334 5 Surat

COVERAGE DETAILS
Your Policy provides protection such as :
Protection towards Third Party Liability

Death or Injury to any Third Party

Personal Accident to Owner Driver (if opted)

Damage to Third Party Property

WE COVER YOU FOR

Third Party Premium
Third Party Baisc Premium 3416.00
Legal Liability to Driver 50.00
PA to Owner Driver 325.00
PA to Unnamed Passenger 250.00
TOTAL TP PREMIUM 4041.00
TOTAL PREMIUM 4041.00
GST 727.38
FINAL PREMIUM 4768.00
Subject to I.M.T Endorsement Nos.(IMT Nos):
IMT - 28
IMT - 16
IMT - 20

IMT-15

ADD ON DETAILS Sum Insured Opted (Yes/No)

Legal Liability to Driver Yes
PA Cover to Un-named Passengers Yes
Consolidated Stamp Duty ₹ 0.5 paid towards Insurance Policy Stamps vide Order No.pay_QdSML2Tlo8L2Uo Dated: 05/06/2025 [Link] of
General Stamp Office, Mumbai

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]
 WHAT YOUR POLICY DOES NOT COVER

Driving under influence of Accident outside India

intoxicating Liquor/Drugs unless opted for

Driving outside purview of

Liability arising out of Limitation of use or Vehicle
Contractual Liability driven for purpose not allowed

HOW TO FILE YOUR CLAIMS WITHOUT ANY STRESS

In the event of loss and / or damage arising out of the use of the insured vehicle giving rise to a probable claim being led by a Third Party towards
bodily injury / death / property damage, please inform the Company at 1800221111 or SMS ‘CLAIM’ to 561612 or email your details on
[Link]@[Link]

RENEWAL

This Policy may be renewed by mutual consent every year and in such event, the renewal premium shall be paid to Insurer on or before the date of
expiry of the Policy or of the subsequent renewal thereof. However, Insurer shall not be bound to give notice that such renewal premium is due.
Toll Free Number Website SMS RENEW Mobile App
POPMCAR00101751926 to Download SBI General Mobile App
1800-102-1111 [Link]
561612 on Playstore or Appstore

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]
 GRIEVANCE REDRESSAL PROCEDURE

If you are dissatisfied with the resolution provided, you may write to
[Link]@[Link] We will look into the matter and decide the same
1 expeditiously within 14 days from the date of receipt of your complaint.
For Senior Citizens: Senior Citizens can reach us at seniorcitizengrievances@[Link]; Toll
Free - 1800 22 1111 / 1800 102 1111 (24*7)

In case, you are not satisfied with the decision/resolution communicated by the above office, or
have not received any response within 14 days, you may send your Appeal addressed to the
Chairman of the Grievance Redressal Committee at : gro@[Link]. or contact at: 022-
42412070
2 Address: Grievance Redressal Officer, 9th Floor, A & B Wing, Fulcrum Building, Sahar Road,
Andheri (East), Mumbai 400 099
List of Grievance Redressal Officers at Branch:
[Link]

In case, you are not satisfied with the decision/resolution communicated by the above office, or

3 have not received any response within 14 days, you may Register your complaint with IRDAI on
the below given link [Link]

If your grievance remains unresolved from the date of filing your first complaint or is partially
resolved, you may approach the Insurance Ombudsman falling in your jurisdiction for
Redressal of your Grievance. The details of the Insurance Ombudsman can be accessed at
4 [Link]
If Your issue remains unresolved You may approach IRDAI by calling on the Toll-Free no.
155255 or You can register an online complaint on the website [Link]

For Insurance Ombudsman Offices, kindly visit our website

[Link] us/Ombudsman Office List

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]
 TERMS AND CONDITIONS

LIMITATION As per Motor Vehicle Rules, 1989 - The Policy covers use of the vehicle for any purpose other than: a)
Hire or Reward, b) Carriage of Goods (other than samples or personal luggage), c) Organized Racing, d)
AS TO USE Pace Making, e) Speed Testing, f) Reliability Trials, g) Any purpose in connection with Motor Trade.

Our
Simply do not use vehicle for the purpose it is not allowed.
Recommendation
Any Person including the Insured provided that a person driving holds an effective driving license at the
DRIVERS time of the accident and is not disqualified from holding or obtaining such a license; provided also that
CLAUSE the person holding an effective learner’s license may also drive the vehicle and that such a person
satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.

Our
Drive only when you hold a Valid Drivers License in India.
Recommendation
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 requirements of the Motor Vehicle Act, 1988.
LIMITS 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
OF LIABILITY
specified Up to ₹ 7,500,00/-.
c. PA Cover for Owner-Driver under Section-III CSI - ₹ 1,500,000 /- (if opted).
Our
Know what your policy covers.
Recommendation
Warranted all damages existing prior to inception of risk are excluded from the scope
of Policy.
SPECIAL
CONDITIONS The Policy has been issued subject to valid Pollution Under Control (PUC) Certificate disclosed by you as
an insured on or before the date of commencement of the Policy. If the PUC Certificate is not found valid
at any point of time during the policy period, the Company reserves the right to cancel the policy.

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]
 IMPORTANT DETAILS

PREVIOUS POLICY DETAILS

Previous Insurer Previous Policy Number Period of Insurance Previous Policy Type

to Comprehensive

Financier Details CPA Nominee Details POSP Details

: NA
POSP Name
: NA
Rupada Jagdishchandra,64,1960-12- POSP PAN Number
,
28,Father
Location
: NA
POSP Code
: NA

Declaration
As part of our Go Green initiative, your policy will be issued digitally to your registered mobile number via WhatsApp, SMS, and email. By
issuing an e-policy, we help conserve the environment by saving a tree. An electronic policy document holds the same legal validity as a
physical copy.

However, if you would prefer to receive a physical copy of your policy document, simply send an SMS with the message "PRINT <Policy
Number>" to 561612 from your registered mobile number.

Liability Only

InsureMo

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]
 PREMIUM RECEIPT

This is to confirm and certify that we have received premium(s) from the below named Policy Holder

Policy Number POPMCAR00101751926

Policy Holder Name Mr RUPDA SUNILKUMAR JAGDISHCHANDRA

Intermediary Name PROBUS INSURANCE BROKER PVT LTD

Receipt Number pay_QdSML2Tlo8L2Uo

Product Name Act Only Insurance Policy - Private Car

Receipt Date 05/06/2025

Policy Start Date 06/06/2025

Policy End Date 05/06/2026

Premium Paid by Mr RUPDA SUNILKUMAR JAGDISHCHANDRA

*Cheque dishonor - If premium paid through cheque, the policy is void ab-initio in case of dishonor of cheque.

Digitally signed by DS SBI

GENERAL INSURANCE
COMPANY LTD
Date: 2025.06.05 [Link]
IST

Authorized Signatory
For SBI General Insurance Company Limited

To Verify your Policy details click/visit [Link]

GST INVOICE : You may download GST invoice from www [Link]\download\

The information provided herein above is for the purpose of illustration only. For more details on risk factors, terms, conditions and exclusions,
please read the Policy wordings ([Link]/portal/act only insurance policy-private car/policy wording) carefully.
Liability Only

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]
 Liability Only
5

PROPOSAL DETAILS

Proposal Transcript For Act Only Insurance Policy - Private Car

Proposer Name Mr RUPDA SUNILKUMAR JAGDISHCHANDRA
Svaminarayan Mandir Jetpur,
Voravad,Rajkot Rajkot,
Proposer Address
Gujarat
360370
Proposer Contact Number 7990491282
Proposer Email Address shivinsurance3@[Link]
Policy POPMCAR00101751926 is issued based on the correct information given by you. In case any information is incorrect or require changes
we request you to revert within a period of 15 days from receipt of this document failing which it will be deemed that you are agreeing to
correctness of the information mentioned in this document.

Details as shared by you with us is as below.

YOUR VEHICLE DETAILS

Registration Number GJ05RJ8165

RTO Location Surat
Engine Number G4LAHM532420
Chassis Number MALA841CLHM272334
P First Purchase / Registration Date 27/03/2020
Year of Manufacture 2017
Vehicle Make Hyundai
Vehicle Model Xcent
Vehicle Variant VTVT SX BSIV
Cubic Capacity / Kilo Watt / Gross Vehicle Weight / Horsepower 1197
Fuel Petrol
Seating Capacity including Driver 5
Carrying Capacity excluding Driver 4

EXPIRING POLICY DETAILS

Details OD Policy Details TP Policy Details

Insurer Name NA
Policy Number NA
Policy Start Date NA
Policy End Date NA
Policy Type NA NA
No Claim Bonus % NA NA
Claim Made No No

COVERAGE & TERMS PROPOSED

From:NA
Period of Insurance Own Damage
To:NA
From:06/06/2025 [Link]
Period of Insurance Third Party
To:05/06/2026 [Link]
: From:06/06/2025 [Link]
Period of Insurance PA cover to Owner Driver
TO:05/06/2026 [Link]

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]
 0.0 0.0
0.0 325
0.0
B00015 0.00.0
250
0.0
0.0 B00016
B00013
0 0.0 0.0
0.0
POPMCAR0010
0.0 50
ADDITIONAL COVERS

PA Cover to Owner Driver of Rs. 15 Lakhs Yes

PA Cover to Unnamed Passenger / Pillion Rider Yes 500000
PA cover to Paid Driver No
Legal Liability to Paid Driver / Employees Yes 1,1
Third Party Property Damage Restriction Limit 750000

50 Add on covers - Kindly refer Policy Schedule

Hypothecation / Lease / Hire Purchaser Name
Policy premium including Tax 4768.00
4768
Valid PUC certificate will be carried in vehicle Yes
1

1 I/We agree to receive policy document on registered mobile number / email address as given in this document.

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
7 insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any
rebate of the premium shown on the policy, nor shall any person taking out or renewing a policy accept any rebate, except such rebate as
may be allowed in accordance with the published prospectus or tables of the insurer. ANY PERSON IN BREACH OF COMPLYING WITH THE
PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE WITH FINE WHICH MAY EXTEND TO RUPEES TEN LAKH.
I/We confirm that premium is paid from bonafide sources of income.

B00

Disclaimer : Corporate & Registered Office: Fulcrum Building, 9th Floor, A & B Wing, Sahar Road, Andheri (East), Mumbai - 400099. | For SBI General
Insurance Company Limited IRDAI Reg. No. 144 dated 15/12/2009 | CIN: U66000MH2009PLC190546 | UIN : IRDAN144RP0001V01200910 | SBI Logo
displayed belongs to State Bank of India and used by SBI General Insurance Co. Ltd. under license.

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]
 CUSTOMER INFORMATION SHEET
This document provides only key information about your policy. Please refer to the policy document for detail terms and conditions.
Description
SI NO Title Policy Clause Number
(Please refer to applicable Policy Clause Number in next column)
1 Name of Insurance Product Motor Act Only- Private Car
2 Unique Identification Number
IRDAN144RP0002V02201819
allotted by IRDAI
3 Structure Limit of liability -Indemnity [Link], section 2a ,2b
4 Interests Insured Interest insured is Third Party liability arising out of insured vehicle 2. Coverage, section 2a
5 Sum Insured / Motor Insured Policy covers the following : 2..Coverage ,section 2a
Declared Value 1. coverage to the Third Party liabilities
2. Third Party Property Damages upto INR 750,000 with an option to
restrict the coverage to INR 6000 whereby there will be reduction in
Liability only premium
6 Policy Coverage (What the This policy covers
policy covers?)
1. Third party liability in case of injury/death of the person, or any 2. Coverage section 2a, 2b
damage caused to the property of the third party
2. If Compulsory Personal Accident cover is opted by you, the
policy covers Personal accident up to Rs 15 lakh for
individual owners while driving.

For complete details on the coverage, limits, exclusions, terms &

conditions, refer policy wording on [Link]
7 Add on Cover Not applicable
8 Loss participation Not applicable
Compulsory Deductible applicable under this policy is - Rs
9 Exclusions The Insurer shall not be liable with respect to [Link] Exceptions
(what the policy does not cover) • Driving without a valid licence

• Driving under the influence of drugs and alcohol

• Own damage cover to vehicle

• Unauthorized usage

• Driving outside geographical area

For complete details on the exclusions, refer policy wording.

10 Special Conditions and Not applicable
Warranties (if any)
11 Admissibility of Claim Admissibility: Admissibility of claim can be done by filing the FIR with the 7. Conditions
police immediately after the accident and file a compensation claim case
in the Motor Accident Claims Tribunal. The claim would not be acceptable
if it falls under General exclusion/condition mentioned in the Policy
Wordings.

Policy can be cancelled on the ground of mis- representation, mis -

declaration, fraud, non-disclosure of material facts.
12 Policy Servicing - [Link] intimation & reaching to our designated officials please contact
Claim Intimation and Processing us at
Email: [Link]@[Link]
Toll-Free number 18001021111
Website: [Link] Whatsapp: 7669800345
Mobile app SMS: 561612

B0

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]
 13 Grievance Redressal and Details of protection of policyholder’s interest-The Company has 9. Grievance Redressal
Policyholders Protection adopted Grievance Redressal Policy, wherein the Grievance Redressal Process
Procedure, details of GRO, Ombudsman details and link to Bima Bharosa
Portal is mentioned below.

Stage 1
To raise the query, you may write to [Link]@[Link]
Toll Free - 1800 102 1111 Customer Care Toll-free number is available
24/7

Stage 2
If you are not satisfied with the decision communicated by the above
office, or have not received any response within 14 days, send your
appeal at : gro@[Link]. or contact at: 022-42412070
Address: Grievance Redressal Officer, 9th Floor, A & B Wing, Fulcrum
Building, Sahar Road, Andheri (East), Mumbai 400 099

List of Grievance Redressal Officers at Branch:

[Link]
[Link]/

Stage 3
In case, you are not satisfied with the decision/resolution communicated
by the above office, or have not received any response within 14 days,
you may Register your complaint with IRDAI on the below given link
[Link]

Stage 4
If your grievance remains unresolved from the date of filing your first
complaint or is partially resolved, you may approach the Insurance
Ombudsman falling in your jurisdiction for Redressal of your Grievance.
The details of the Insurance Ombudsman can be accessed at
[Link]

If Your issue remains unresolved You may approach IRDAI by calling on

the Toll-Free no. 155255
List of Ombudsman offices with contact details are attached as an
Annexure-1. For updated status, please refer to website
[Link]

14 Obligations of prospective The Policy shall be void and all premium paid hereon shall be forfeited to
Policyholder / Customer the Insurer, in the event of misrepresentation, misdescription or non
disclosure of any material fact by the policyholder pertaining to the
proposal form, written declarations or any other communication
exchanged for the sake of obtaining the insurance policy by the Insured.

Disclosure of other material information during the policy period:

1. Change in insured name
2. Change in the vehicle details i.e make, model, cc, extra fitments,
engine & chassis no, class of vehicle. In fact all (In fact, all relevant
details are in the RC book/card and a copy of same may be
handed over) Tax paid details; Certificate of fitness, license
validity etc.
3. Previous policy details (ie. Disclosure of NCB, previous claim
details)
Declaration by the Policyholder:

I have read the above and confirm having noted the details.
Place:
Date: (Signature of the Policyholder)
Note: For product related documents including Customer Information Sheet, kindly refer to the below link: [Link]
In case of any conflict, the terms and conditions mentioned in the policy document shall prevail

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: [Link]