Service Branch Address:

Old No : 113 & 114 , New No. 18 & 20 ,No.4B, 4th Floor, " A" Block, Mena Kampala Arcade,Sir Theyagaraya Road,T.Nagar,X1-T Nagar ,CHENNAI -
600017.

Oct 15, 2018

Mr.RAJIV PAL
L703, SHILALEKH FLATS,
SHAHIBAG

AHMEDABAD, GUJARAT
380004
Telephone : 07925624796
Mobile : 9998972122

Certificate of Insurance and Policy No.

VPB0000609000104

Dear Customer,

Thank you for choosing Royal Sundaram as the Insurer of your vehicle. We are
delighted to have you as our customer.
We are enclosing the following
1. Certificate of Insurance & Policy Schedule pertaining to the insurance of your
vehicle
2. Claims Guide for preferring a claim for your vehicle loss or damage
The Certificate of Insurance & Policy Schedule is an important document that
you may be required to produce whilst your vehicle is in use. We request you to
verify the above documents and ensure everything is in order. In case of any
discrepancies, please contact us immediately.
To read the “policy” & “add on” terms, conditions, exceptions and applicable
endorsement, please log on to our website www.royalsundaram.in
Should you have any queries, please contact our Customer Service helpline
number 1860-425-0000. You may also write to
[email protected]
Assuring you of our best services at all times.
Yours sincerely,
Authorized Signatory

Note:
Please read through the claims guide provided in this pack to understand the claim process. For better understanding you can refer or
download the vernacular claims guide available in our website.
To download the claim form and to know more about Royal Sundaram products please log on to www.royalsundaram.in

13231a777a978f08247d2df3bae3291d
Service Branch Address:
Old No : 113 & 114 , New No. 18 & 20 ,No.4B, 4th Floor, " A" Block, Mena Kampala Arcade,Sir Theyagaraya Road,T.Nagar,X1-T Nagar ,CHENNAI -
600017.

Oct 15, 2018

Intermediary OA505227
Mr.RAJIV PAL Code:
L-703, SHILALEKH FLATS,
SHAHIBAG Intermediary Internet- PolicyBazaar
AHMEDABAD,GUJARAT Name: Insurance Web
380004
Telephone: 07925624796 Aggregator Pvt. Ltd
Mobile: 9998972122
Contact: -

CERTIFICATE OF INSURANCE & POLICY SCHEDULE

(See Form 51 of The Central Motor Vehicles Rules, 1989) Motor Vehicles Act, 1988

Certificate of Insurance and Policy No.

VPB0000609000104

INSURED DETAILS
Insured Date Geographical Registration Registration
Name of Insured Occupation
of Birth Area Authority Date
Corporate
Mr.RAJIV PAL 12/07/1966 India AHMEDABAD 07/12/2006
Executive

INSURED'S DECLARED VALUE (IDV) (in Rs.)

Non Electrical / Value Loss For Life
For the For Total Invoice
Electrical Electronic of CNG Of Time
Vehicle Trailers IDV Price
Accessories Accessories Kit Baggage Road Tax
213,216 0 0 0 0 213,216 0 0 0
PRIVATE CAR VEHICLE DETAILS
Registration Number GJ01HL9387 Type of Body Sedan
Engine Number 708661702661 Cubic Capacity 1,599
Chassis Number 00000005585 Year of Manufacture 2006
Make of the Vehicle HYUNDAI MOTORS LTD. Seating Capacity (including Driver) 5
Model Description Verna I Total Premium (in Rs.) 12,753
LIMITATIONS AS TO USE: DRIVER:
The Policy covers use of the vehicle for any purpose other than: Any person including the Insured
a) Hire or Reward, Provided that a person driving holds an effective Driving Licence at
b) Carriage of goods (other than samples or personal luggage) the time of the accident and is not disqualified from holding or
c) Organised racing obtaining such a License.
d) Pace making Provided also that the person holding an effective Learner's Licence
e) Speed testing may also drive the vehicle and that such a person satisfies the
f) Reliability Trials requirements of Rule 3 of The Central Motor Vehicles Rules, 1989.
Any purpose in connection with Motor Trade.
LIMITS OF LIABILITY:
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 Vehicles Act, 1988.
Under Section II-1 (ii) of the Policy - Damage to Third Party Property - Rs 750,000 (as per IMT 20) - In respect of any one claim or series of claims arising out of one event.
Personal Accident cover for Owner - Driver under section III: CSI - Rs.1,500,000/-
DEDUCTIBLE: Total deductible Rs. 2,000 in respect of each and every claim. (Compulsory Deductible [Rs.2,000], Voluntary Deductible [Rs. 0],
Imposed Deductible [Rs. 0] and Loss Of Baggage Deductible[Rs. 0] )

Document Code: DINWSV999999 Certificate of insurance & policy schedule continued in Page 2
13231a777a978f08247d2df3bae3291d

You can reach us through the details given below Mon - Sat 8.00am to 9.00pm and Sunday up to 5.00pm
Call:1860 425 0000 SMS:type <MOTORCLAIMS> and send to 567675

E-Mail:[email protected] www.royalsundaram.in
 CERTIFICATE OF INSURANCE & POLICY SCHEDULE (CONTINUED)
(See Form 51 of The Central Motor Vehicles Rules, 1989) Motor Vehicles Act, 1988

Policy No.VPB0000609000104
Premium in Premium in
A - OWN DAMAGE B - LIABILITY
Rs. Rs.
1. Basic premium on Vehicle and Non-Electrical Accessories 3,942.00 1. Basic premium including premium for TPPD 7,890.00
2. Electrical & Electronic accessories @ 4%(IMT 24) 0.00 2. Less: For restricted TPPD cover for Rs.6000 (IMT 20) 0.00
3. Bi-Fuel kit (CNG/LPG) @ 4% (IMT 25) 0.00 3. Bi-Fuel kit (CNG/LPG) 0.00
4. Trailers (IMT30) 0.00
ADD: ADD:
4. Trailer 0.00 Personal Accident Benefits
5. Geographical Area Extn.Endt.IMT-1 0.00 5. Under Section III (Owner Driver), CSI Rs.1,500,000 750.00
6. 30% for Imported vehicles without custom duty (IMT 19) 0.00 6. Geographical Area Extn.Endt.IMT-1 0.00
7. Named Passengers, CSI Rs.0.00 each as per list
7. Fibre Glass Tanks 0.00 0.00
attached (IMT 15)
8. 60% on OD Premium for Driving Tution 0.00 0.00
8. Unnamed Passengers, CSI Rs.0 each (IMT 16)
9. Additional Towing Charges. Rs.0 0.00
9. PA Cover to Paid Driver, CSI Rs.0 (IMT 17) 0.00
10. For any Other extra 0.00
Less: ADD:
10. Discount for Anti-theft devices (IMT 10) 0.00 Legal Liability:
11. Automobile Association Discount (IMT 8) 0.00 10. To Paid Driver (IMT 28) 0.00
12. Voluntary Deductible(IRDAN102A0006V01200910)of Rs.0 0.00
11. To Paid Employees (IMT 29) 0.00
(IMT 22 A)
13. 50% Discount for Vehicles specially designed/modified
12. For any other extra 0.00
for blind,handicapped and mentally challenged persons 0.00
13. TOTAL LIABILITY PREMIUM (B) 8,640.00
14. Deduct:45% No Claim Bonus -1,773.90 14. Add: Underwriting Loading % 0.00
15. Add: Underwriting Loading 0.00 15. NET PREMIUM (A + B) 10,808.00
Add: Additional Cover for Package Policies
16. Depreciation Waiver (IRDAN102A0011V02201213) 0.00
17. Windshield Glass (IRDAN102A0004V01200910) 0.00
18. Facilities in Lieu of Spare Car (IRDAN102A0007V01200910) 0.00
19. Full Invoice Price Insurance (IRDAN102A0008V01200910) 0.00 ADD: IGST 1,945.44
20. Life Time Road Tax (IRDAN102A0005V01200910) 0.00
21. Loss of Baggage (IRDAN102A0009V01200910) 0.00
22. NCB Protector Cover (IRDAN102A0002V01201314) 0.00
23. Aggravation Cover (IRDAN102A0001V01201314) 0.00
24. Key Replacement Cover (IRDAN102A0001V01201516) 0.00
25. Tyre Cover Clause (IRDAN102A0003V01201718) 0.00
26. TOTAL OWN DAMAGE PREMIUM (A) 2,168.00 16. TOTAL PREMIUM PAYABLE 12,753.00
No Claim Bonus:
a) No Claim Bonus will only be allowed provided the policy is renewed within 90 days of the expiry date of the previous year. b) The insured is entitled for a No Claim Bonus (NCB)
on the Own Damage Section of the policy, if no claim is made or pending during the preceding year(s), as per the details given below:

Period of Insurance % of NCB on OD Premium Subject to IMT Endt. Nos. & Memorandum 22
(refer Terms & Conditions for relevant wording)
The preceding year 20 Under Hire Purchase/Lease Agreement /Hypothecated with
Nominee Name Nominee Age Relationship with
Preceding two consecutive years 25 Shivani Pal 48 SPOUSE
Preceding three consecutive years 35 Guardian Name Guardian Age Guardian Relation
0
Preceding four consecutive years 45 Date and Signature of Proposal/Renewal notice 01/11/2018

Preceding five consecutive years 50

In Witness whereof this Policy has been signed at Chennai on 28/09/2018 in lieu of Cover note No. EVP0054478 dated Receipt No. . 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 the Motor Vehicles Act, 1988.
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 Vehicles Act, 1988 is recoverable from the Insured. See the clause headed "AVOIDANCE
OF CERTAIN TERMS AND RIGHT OF RECOVERY" under Policy Terms and Conditions.
For Royal Sundaram General Insurance Co. Limited

Consolidated Stamp Duty Paid to Govt of TamilNadu Authorised Signatory

This document is digitally signed, hence counter signature / stamp is not required.

GSTIN : 33AABCR7106G1ZQ UIN: PAN Number : AABCR7106G

For Legal interpretation, English version will hold good.
13231a777a978f08247d2df3bae3291d
Signature Not
Verified
Digitally signed by
THIRUNAVUKKARASU S
You can reach us through the details given below Mon - Sat 8.00am to 9.00pm and Sunday up to 5.00pm Date: 2018.11.14
20:54:15 IST
Call:1860 425 0000 SMS:type <MOTORCLAIMS> and send to 567675 Reason: For
RoyalSundaram
Location: Chennai
E-Mail:[email protected] www.royalsundaram.in
 GST Invoice
Royal Sundaram General Insurance Co. Limited
:X1-T Nagar
Address: Old No : 113 & 114 , New No. 18 & 20 ,No.4B, 4th Floor, " A" Block, Mena Kampala Arcade,Sir Theyagaraya
Road,T.Nagar,X1-T Nagar ,CHENNAI - 600017.
GSTIN: 33AABCR7106G1ZQ

Policy Number : VPB0000609000104

GST Invoice Number : VPB000060904000
Invoice Date : 28/09/2018

Address of insured:
Insured Name: Mr.RAJIV PAL
L703, SHILALEKH FLATS,
SHAHIBAG

AHMEDABAD
State:GUJARAT
Pincode: 380004

Accounting code of service : 997134

Description of service: Motor vehicle insurance services

Taxable Premium 10,808.00

IGST 18.00% 1,945.44

Gross Premium 12,753.00

Indication if tax payable under reverse charge - No

Note:“This document is digitally signed”

“This document is electronically generated.This document should be issued along with the Policy document.This document stands
invalid,if issued separately”

You can reach us through the details given below Mon - Sat 8.00am to 9.00pm and Sunday up to 5.00pm
Call:1860 425 0000 SMS:type <MOTORCLAIMS> and send to 567675

E-Mail:[email protected] www.royalsundaram.in