LIBERTY GENERAL INSURANCE LIMITED

PRIVATE CAR POLICY ­ BUNDLED COVER

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
IMPORTANT ­ 1) The Validity of this Certificate of Insurance cum Schedule is subject to realization of the premium cheque.
2) No Claim Bonus will only be allowed provided the Policy is renewed within 90 days of the expiry date of the previous policy.
3) In the event of misrepresentation, fraud or non­disclosure of material facts, the company reserves the right to cancel the policy from inception.
Policy Issuing Office 10th Floor, Tower A Peninsula Business Park, Ganpath Rao Kadam Marg Lower Parel MUMBAI MAHARASHTRA ­ 400013 Phone: +91 22 6700 1313 Fax: +91 22
6700 1606
Policy Servicing Office Diyan Complex, Shop no.23/e1, 1ST Floor, Opp KHB Complex, Kuvempunagar, MYSURU KARNATAKA 570023 PH: +91 821 2462510 FAX: +91 0 0
Period of insurance
(Section I ­ Own Damage) From 20:18 Hrs of 27/06/2023 To Midnight of 26/06/2024
(Section II ­ Liability) From 20:18 Hrs of 27/06/2023 To Midnight of 26/06/2026
(Section III ­ PA OWNER­DRIVER ) From 20:18 Hrs of 27/06/2023 To Midnight of
26/06/2026
Policy No 2011­500204­23­7000705­00­000
Geographical Area India
Insured KALAIARASI N Policy Issued On 30/06/2023
Address W/O NANDESHWARAN BHAGATH SINGH ROAD Covernote No/Ecovernote No 201150020423700070500000
JAYANAGARA JAYANAGARA EXTENSION 2ND STAGE HASSAN Covernote Date
HASSAN RTO Location BENGALURU Zone Zone­A
HASSAN KARNATAKA 573201 UIN CODES IRDAN150RP0004V01201819
Customer UIN
Contact Number (M) +917022033861 Customer ID 4111346159 POSP Name: VENKATACHALAM R P
GSTIN No/State Name NA/KARNATAKA
POSP Code: POS1011868
Aadhaar Card/PAN: 941440920870 / AAVPV1027F
POSP Contact Number: 9611586259

Agent Name
Agent Code Agent Contact No
INSURED MOTOR VEHICLE DETAILS AND PREMIUM COMPUTATION
Year of
Manufacture/Date Licensed Carrying
Registration Trailer Trailer Trailer
Of Engine No. Chassis No. Make/Model/Type of Body CC/HP/GVW/KW capacity including
Mark & No. Registration/Invoice Registration No. Chassis No. IDV
Driver
date
2023/27­06­ VOLKSWAGEN/TAIGUN
NEW 2023/27­06­2023
DTB119745 MEXB23CW2PT013692
TOPLINE 1.0 TSI MT/Suv
999 5

IDV (INSURED'S DECLARED VALUE)

Year IDV of Vehicle( ) Trailers( ) Side Car( ) Non Electrical Accessories Electrical/Electronic Bi Fuel kit (CNG/LPG)( ) Total Value ( )
( ) Accessories( )
1 1,514,905.00 0.00 0.00 0.00 0.00 0.00 / 0.00 1,514,905.00
Section I ­ OWN DAMAGE (A) Section II ­ LIABILITY (B)
Own Damage Premium on vehicle and accessories Third Party Premium
Basic Cover Basic Cover
Basic ­ OD 16,319.34 Basic ­ TP 6,521.00
TOTAL OWN­DAMAGE PREMIUM (A) 16,319.55 Legal Liability
Section I ­ ADD ON COVERS (C) LL to Paid Driver IMT 28 150.00
Passenger Assist IRDAN150RP0004V01201819/A0025V01201819 250.00 TOTAL LIABILITY PREMIUM (B) 6,671.00
Consumables Cover IRDAN150RP0004V01201819/A0023V01201819 1,514.91 Section III­ PA OWNER­DRIVER (D)
Engine Safe Cover IRDAN150RP0004V01201819/A0032V01201819 1,514.91 PA Owner Driver (3 Year From Date of Inception) 1,022.00
Gap Value (Incl. Taxes & Regn. Charges) Net Premium(A+B+C+D) Taxable Value 33,901.00
1,514.91
IRDAN150RP0004V01201819/A0024V01201819
CGST(9% ­ KARNATAKA) 3,051.09
Roadside Assistance IRDAN150RP0004V01201819/A0026V01201819 249.00
SGST(9% ­ KARNATAKA) 3,051.09
Depreciation Cover IRDAN150RP0004V01201819/A0022V01201819 4,544.72
TOTAL POLICY PREMIUM 40,003.00
Key Loss Cover @ SI 20,000.00/­
300.00
IRDAN150RP0004V01201819/A0031V01201819
TOTAL ADD­ON COVER PREMIUM (C) 9,888.45

Hire Purchase/ Lease /Hypothecated with SBI BANK­HASSAN

LIMITATION AS TO USE : The Policy covers use of vehicle for any purpose other than: a) Hire or Reward b)Carriage of goods(other than sample of personal luggage) c)
Organized racing d)Pace Making e)Speed Testing f)Reliability Trial g)Use in connection with motor trade.
DRIVERS CLAUSE
Persons or Classes of Person entitled to drive:Any person including the insured provided that a person driving holds an effective driving license at the time of the accident and is not
disqualified from holding or obtaining such a license.Provided also that 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.
LIMITS OF LIABILITY
Deductible Compulsory Deductible: Rs 1000/­, Under Section II­I (i) of such amount necessary to Under Section II­I 750,000.00 P.A. cover for 1500000
under Voluntary Deductible: Rs 0 /­, the policy (Death of or meet the requirements of (ii) of the policy owner­ Driver
section ­ I Imposed Excess : Rs 0 /­. bodily injury): motor vechile Act,1988 (Damage to third under section
Additional excess : Rs /­ party property) III : CSI
Theft excess : Rs /­
EV Secure­Damage to Charger Deductible :
Rs 0 /­
EV Secure­Damage to Property
Deductible : Rs 0 /­
Subject to I.M.T Endorsement Nos. AD01,AD02,AD04,AD05,AD06,AD07,AD10,IMT 22,IMT 28,IMT 7
Passenger assist cover details:­Hospital Cash: Rs 1500 per day for 30 days (per Pax.), Medical Expenses: Rs 10,000 (per Pax.), Ambulance Charges: Rs. 5000
NOMINATION DETAILS
Name of the Nominee Relationship with Insured Name of Appointee (if nominee is minor) Relationship with the Nominee
NANDESHWARAN . Spouse
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 M.V. Act,
1988.
In witness whereof this Policy has been signed at Mumbai on 30/06/2023
Receipt No: 10250020423100256111
In case of Claims, Please contact us at : Toll Free No ­ 18002665844,
email id ­ [email protected]
% DSUnknown
q
1G
1g
0.1 0 0 0.1 9 0 cm
0 J 0 j 4 M []0 d
1i
0g
313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l

Date of Issue : 30/06/2023

100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
h
308 214 170 -164 re
f
0.44 G
1.2 w
1 1 0.4 rg
287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c
478 762 414 786 365 786 c
260 786 245 707 239 652 c

Place : Mumbai
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
h
282 240 170 -164 re
B
Q

Consolidated Stamp duty has been paid as per letter of Authorization no. LOA/CSD/18/2023/2131
Dated 21/04/2023 issued by Main Stamp Office, Mumbai. ** Not Applicable for the State of Jammu & Digitally signed by: SACHIN
Kashmir. JOSHI
Invoice No. 2923011001648233 Date: 2023-07-05 07:18:59
For Liberty General Insurance Limited
IST
Branch GSTIN No : 29AABCL9950A1ZH Location: Mumbai
SAC Code : 997134; Description of Service : General Insurance
Service; Place of Supply : KARNATAKA/29
IRDA Regn. No. 150
CIN No. U66000MH2010PLC209656
Tax is not payable under reverse charge by the recipient
I/We hereby declare that though our aggregate turnover in any
preceding financial year from 2017­ 18 onwards is more than the
aggregate turnover notified under sub­ rule (4) of rule 48, we are not Authorised Signatory

required to prepare an invoice in terms of the provisions of the said

s u b­ rule
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 be good.

% DSUnknown
q
1G
1g
0.1 0 0 0.1 9 0 cm
0 J 0 j 4 M []0 d
1i
0g
313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l
100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
h
308 214 170 -164 re
f
0.44 G
1.2 w
1 1 0.4 rg
287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c
478 762 414 786 365 786 c
260 786 245 707 239 652 c
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
h
282 240 170 -164 re
B
Q

Digitally signed by: SACHIN

JOSHI
Date: 2023-07-05 07:18:59
IST
Location: Mumbai
Insurance is the subject matter of the Solicitation IRDAN150RP0004V01201819
Liberty General Insurance Limited
10th Floor, Tower A, Peninsula Business Park,
Ganpath Rao Kadam Marg, Lower Parel
MUMBAI ­ 400013
Phone: +91 22 6700 1313 Fax: +91 22 6700 1606
Email: [email protected]
IRDA registration number: 150 • CIN: U66000MH2010PLC209656

INFORMATION SUMMARY ­ PROPOSAL

(8 (2) of the Insurance Regulatory & Development Authority (Protection of Policyholders Interests) Regulations, 2017 or any amendment or repealment thereto)
To, Date: 30/06/2023
KALAIARASI N
W/O NANDESHWARAN BHAGATH SINGH ROAD JAYANAGARA JAYANAGARA EXTENSION 2ND STAGE HASSAN HASSAN
(M) +917022033861
[email protected]

Dear Customer,

We thank you for choosing us for your insurance requirement. We, at Liberty General Insurance Limited, believe 'Insurance' is not only an assurance to compensate in the event of an
unfortunate circumstance, but one that signifies protection and support you can count on when you need it the most. We are firmly committed to stand beside you and fulfill your insurance
requirement whenever the need arises.

We write to inform you that we have received the below details for insuring your under mentioned vehicle;

Period of insurance
(Section I ­ Own Damage) From 20:18 Hrs of 27/06/2023
To Midnight of 26/06/2024
(Section II ­ Liability) From 20:18 Hrs of 27/06/2023 To
Product Name PRIVATE CAR POLICY ­ BUNDLED COVER Midnight of 26/06/2026
(Section III ­ PA OWNER­DRIVER ) From 20:18 Hrs of
27/06/2023 To Midnight of 26/06/2026

Policy No: 2011­500204­23­7000705­00­000

Motor Vehicle details

Licensed
Vehicle
Registration RTO Year of Manufacture/Date Trailer Chassis Carrying
Engine No. Chassis No. Sub Make/Model/Type of Body CC/HP/GVW/KW
Mark & No. Location Of Registration/Invoice Date No./Registration No. Capacity
Class
Including Driver
2023/27­06­2023/27­06­ VOLKSWAGEN/TAIGUN
NEW BENGALURU
2023
DTB119745 MEXB23CW2PT013692 /
TOPLINE 1.0 TSI MT/Suv
999/ 5

IDV (INSURED'S DECLARED VALUE)

Year IDV of Vehicle( ) Trailers( ) Side Car( ) Non Electrical Accessories Electrical/Electronic Bi Fuel kit (CNG/LPG)( ) Total Value ( )
( ) Accessories( )
1 1,514,905.00 0.00 0.00 0.00 0.00 0.00 / 0.00 1,514,905.00

Add on Covers Hire Purchase/Lease/Hypothecated with: Voluntary deductible

Passenger Assist
IRDAN150RP0004V01201819/A0025V01201819
Consumables Cover
IRDAN150RP0004V01201819/A0023V01201819
Engine Safe Cover
IRDAN150RP0004V01201819/A0032V01201819
Gap Value (Incl. Taxes & Regn. Charges)
SBI BANK­HASSAN 0
IRDAN150RP0004V01201819/A0024V01201819
Roadside Assistance
IRDAN150RP0004V01201819/A0026V01201819
Depreciation Cover
IRDAN150RP0004V01201819/A0022V01201819
Key Loss Cover @ SI 20,000.00/­
IRDAN150RP0004V01201819/A0031V01201819

Previous policy details

Previous Policy Number Previous Insurer Name Previous Policy Period Previous Policy Type Previous Year NCB Claim made in Previous Policy

The above information provided has been recorded by us under Regulation 4 (4) of the Insurance Regulatory & Development Authority (Protection of Policyholders Interests) Regulations,
2002 and believing the furnished information as correct, we have issued the enclosed insurance policy for your said vehicle. We are hereby providing the information for your confirmation
and records.

For any further assistance please feel free to write to us on [email protected] or call us on our Toll Free number 1800 266 5844 (between 8:00am to 8:00pm, 7 days of the
week), you can also visit our nearest branch, our representatives will be glad to help you.

To enable us to serve you better, we request you to check your contact details and communicate to us by any of the above medium incase any changes required.

In the absence of any communication from you in this regards within a period of 15 days of receipt of this letter, we would take this as a confirmation that the issued policy is in order and as
per your requirement. Incase, any of the above information is found to be incorrect subsequently, the company may, at its sole discretion cancel the policy or any part thereof as deemed fit.

Correct No Claim Bonus (NCB) declaration on the part of insured is extremely important for a seamless customer experience and if the NCB declaration is found to be incorrect, all benefits
under Section I (Own Damage) of the Policy stand forfeited. Hence, we strongly recommend that you verify the NCB details on your policy and in case of any correction, write to us at
[email protected] or call us on 18002665844 not later than 15 days from the date of this letter.

Liberty General Insurance Limited,

% DSUnknown
q
1G
1g
0.1 0 0 0.1 9 0 cm
0 J 0 j 4 M []0 d
1i
0g
313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l
100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
h
308 214 170 -164 re
f
0.44 G
1.2 w
1 1 0.4 rg
287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c
478 762 414 786 365 786 c
260 786 245 707 239 652 c
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
h
282 240 170 -164 re
B
Q

Digitally signed by: SACHIN

JOSHI
Date: 2023-07-05 07:18:59
IST
Location: Mumbai
Insurance is the subject matter of the Solicitation IRDAN150RP0004V01201819
Authorized Signatory

% DSUnknown
q
1G
1g
0.1 0 0 0.1 9 0 cm
0 J 0 j 4 M []0 d
1i
0g
313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l
100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
h
308 214 170 -164 re
f
0.44 G
1.2 w
1 1 0.4 rg
287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c
478 762 414 786 365 786 c
260 786 245 707 239 652 c
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
h
282 240 170 -164 re
B
Q

Digitally signed by: SACHIN

JOSHI
Date: 2023-07-05 07:18:59
IST
Location: Mumbai
Insurance is the subject matter of the Solicitation IRDAN150RP0004V01201819