Bajaj Allianz General Insurance Company Limited
6TH FLOOR, MANI SQUARE, 164, ,CANAL CIRCLE ROAD,MANI SQUARE PREMISES,KOLKATA,WEST BENGAL,700054 .
GSTIN Number: 19AABCB5730G1ZU
IRDA Registration No: 113 UIN No: IRDAN113RP0008V01201819
MOTOR TWO - WHEELERS POLICY BUNDLED CUM RECEIPT
(Form 51 of the central motor vehicle rules, 1989)
Policy No/Issue Dt &
YHM/BAG2508284160 / 03-Aug-2025 12:08 Proposal No. & Date YC2508031146265536 & 03-Aug-2025 12:08
Time
Insured Name Mr ANANDA AGRAHARI Period Of Own Damage Cover 03-Aug-2025 (12:08) to 02-Aug-2026 (Midnight)
Period Of Liability Cover 03-Aug-2025 (12:08) to 02-Aug-2030 (Midnight) Period Of PA Owner Driver 03-Aug-2025 (12:08) to 02-Aug-2026 (Midnight)
Previous Insurer N/A Previous Policy No N/A
Reg. Address 91/21 Q ROAD HAORA CORPORATION HAORA KOLKATA WEST Comm. Address 91/21 Q ROAD HAORA CORPORATION HAORA KOLKATA WEST
BENGAL 711105 BENGAL 711105
Make Model Sub Model Cubic Capacity Manufacturing Year Seating Capacity
RAY Z (RayZR
YAMAHA BKXG00 125 2025 2
(Disc) DLX)
D.O.B Mobile Number Email Pan Number GSTIN Product Type
20-Dec-2003 74*****7935 AN**********************.COM NA NA ADDON
Body Type Registration No. RTO Hypothecation/Lease* Fuel Type Chassis No
SOLO NEW HOWRAH Yes PETROL ME1SEL865S0007609
Engine No Invoice Date Vehicle IDV Elec. Accessories Non-Elec. Accessories Total IDV
E33SE0950404 03-Aug-2025 83914 0 0 83914
Schedule of Premium (Amount in Rs.)
Own Damage Premium (A) Liability Premium (B)
Basic Premium Basic Third Party Liability (Including TPPD - 0) 3851
Vehicle 1406 Sub Total (Third Party Liability) 3851
Non-Elec. Accessories 0 PA Cover For Owner Driver of Rs.1500000(IMT-15) For 1 Year 525
Elec. Accessories (IMT-24) 0 Legal Liability To Passenger 0
Sub Total (Basic Premium) 1406 PA Cover (0 Per Person) for 2 Persons(IMT-16) 0
IMT 33 0 Geographical Area Extension (IMT-1) 0
Add On Coverages (Nil Depreciation) 168 Sub Total (PA Cover) 525
Add On Coverages (RTI) 168 Net Liability Premium (B) 4376
Add On Coverages (Engine Protector) 84
Add On Coverages (Consumable Cover) 84
Geographical Area Extension (IMT-1) 0 Total Premium (A+B) 6286
Sub Total-Addition 504 SGST(9 %) 566
Deductibles CGST( 9%) 566
Voluntary Deductibles (0) (IMT-22A) 0 IGST(0 %) 0
Anti Theft Device (IMT-10) 0
AA Membership (IMT-8) 0 Gross Premium Paid 7418
No Claim Bonus (0%) 0 Note: [Link] issuance is subject to realization of cheque
Handicap Discount (IMT-12) 0 [Link] Stamp duty paid to state exchequer
Sub Total (Deductibles) 0 [Link] policy is subject to compulsory deductible of Rs.100 (IMT-22)
Net Own Damage Premium (A) 1910 *Subject to IMT Endt. Nos.& Memorandum: 15,22
UIN Details: Nil Depreciation ,Consumable Cover ,RTI ,Engine IRDAN113RP0008V01201819/A0024V01201819 ,IRDAN113RP0008V01201819/A0025V01201819
Protector ,IRDAN113RP0008V01201819/A0031V01201819
Name of Nominee Age Relationship with Insured Name of Appointee Relationship with Nominee
GEETA AGRAHARI 45 MOTHER
Insured Declared Value :The schedule of age-wise insured declared(IDV) as shown in the below table is applicable for the purpose of Total loss including Theft/Constructive Total Loss
(TL/CTL) claims only on basis of loss date falling in the respective year. A vehicle will be considered to be a CTL, where the aggregate cost of retrieval and/or repair of the vehicle subject to
terms and conditions of the policy exceeds 75% of the IDV.
Tenure 03-Aug-2025 to 02-Aug-2026 - - - -
IDV 83914 0 0 0 0
Limitations as to use : The policy covers use of the vehicle for any purpose other than (1) Hire or Reward (2) Carriage of goods (other than samples or personal luggage) (3) Organized racing (4) Pace making (5) Speed testing (6) Reliability trials (7) Any purpose in connection with motor
trade.
Drivers Clause : Any person including the insured: Provided that the person driving holds an effective driving license at the time of the accident and is not disqualified from holding or obtaining such license. Provided also that the person holding an effective learners license may also drive
the vehicle & that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.
Limits of Liablity Clause : Under Section II-1(i) of the policy-Death of or bodily injury: Such amount as is necessary to meet the requirements of the Motor Vehicle Act [Link] Section II-1 (ii) of the policy-Damage to third party property is Rs.1 lakhs PA Cover Under Section III for
Owner-Driver is Rs. 1500000 .
Grievance Clause : For resolution of any query or grievance, Insured may check Grievance redressal policy at [Link] or connect with the respective servicing office of insurance company. In the event of unsatisfactory response, he/she
may approach the insurance ombudsman for the redressal of grievance at [Link] or on website of General Insurance Council: [Link]
Hypothecation Details: HDFC BANK LTD, N S ROAD, KOLKATA , CPA Waiver reasons : NA
Important Notice : The insured is not indemnified, if the vehicle is used or driven otherwise than in accordance with the schedule. Any payment made by the company by reasons 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 & RIGHT OF RECOVERY For legal interpretation, English version will hold good.
I/we hereby certify that the policy to which this certificate relates as well as this certificate of insurance are issued in accordance with the provisions of Chapter X and Chapter XI of Motor Vehicle Act, 1988 In case this policy is cancelled for any reason before 31st October of the
following year, the refund calculated as per terms of the policy along with corresponding amount of GST would be refunded. However, in case this policy is cancelled beyond the said date (31st October of the following year), only the refund calculated as per terms of the policy would be
refunded and any GST amount would NOT be refunded owing to the restrictions prescribed under the GST law. However, an unregistered GST customers can apply for refund of the GST amount from the government directly in FORM GST RFD-01 (along with relevant documents),
within the prescribed timelines as per Circular No. 188/20/2022-GST dated 27/12/2022.
Receipt No:YC2508031146265536 , Receipt Date:03-Aug-2025, Payment Mode:HDFC Credit Card
Scan QR To View Policy MISP Details Broker Details Signature
For & On Behalf of Bajaj Allianz General Insurance Company
Limited
Broker Code : DB-403/08
MISP Code : TTIBI/Y/103392624
SAC:997134 , Broker Name : Toyota Tsusho Insurance Brokers
Description Of Service:MOTOR VEHICLE INSURANCE India Pvt Ltd
SERVICES,
Place Of Supply:WEST BENGAL (State Code :33) Broker Address :Sai Tech Park, No.105, 2nd Floor,
Anna Salai, Little Mount, Guindy, Chennai - 600032.
Authorized Signatory
Please contact for Renewal assistance - /9930315451 , Claims assistance - :9147048004,SRFB TRADERS PVT LTD., WEST BENGAL (or) For Renewal/Claim Visit Our Website : [Link]
