Bajaj Allianz General Insurance Company Ltd.

Issuing Office: Ahmedabad Branch,4th Floor, Turquoise,Nr. Panchvati Circle,C.G

Road,Ellisbridge,Ahmedabad079-26408006/40028866

Date: 26-APR-2016 Reference No: REF74085513

Generated by : dipti.patel2202@general.bajajallianz.co.in
RAVI

Quote-cum-Proposal
Dear Sir/Madam,
Re.: Your enquiry for premium quotation for vehicle
We thank you for your enquiry for quote on insurance premium for your registered as Private Car - Package Policy .
Details of your requirement are noted below -

Intermediary ID 10043044
Sub Intermediary ID

Make Model SubType CC Fuel Year of Registered NCB at

Manufature Seating Renewal
HYUNDAI i 20 1.2 MAGNA 1197 Petrol 2015 5 0%
(O)

Vehicle IDV Value of Electrical Value of Non- Value of CNG/LPG Total IDV
Accessories Electrical Accessories Unit -extra fitted
451338 451338

Proposed Insurance Policy Expiry Date Date of Vehicle Pin Code of your Voluntary Excess
commencement date Registration normal place of
stay
30-APR-2016 29-APR-2017 29-APR-2015 380060 0

Based on the cited details, we are pleased to quote our premium as under: (* All figures in Rupees)

Net OD Premium Net TP Premium Total Premium Service Tax Swachh Bharat/ Final Premium
Edu. Cess
11113 2337 13450 1883 67 15400
Important Notes :

1. This quotation is based on information provided to us and is subject to relevant proofs being submitted and
inspection of vehicle at the time of issuance of policy. Quote is subject to change based on documentation and
in case actual information at the time of issuance differs from the above.
2. This submission is only a quotation and not an insurance policy or cover note. The insurance coverage would start
only after issuance of policy and receipt of payment of premium subject to terms of policy.
3. This quote is valid for 15 days from Proposed Insurance commencement date noted above.
4. The premium quoted is for an insurance period from 30-APR-2016 to 29-APR-2017 .
5. You are requested to return duly signed copy of this quote as a confirmation of acceptance of the terms and
reconfirmation of information provided above.
6. Alternately you may send your objection, what so ever with regard to the above quote or the terms and condition
of policy issued, within 7 days from the date of this quote, failing which it will be concluded that you are fully
satisfied and have accepted the quote including the terms and condition of the policy and the correctness of the
information provided above.
7. Policy would be issued after tendering full premium quoted above and subject to inspection of vehicle where
required.
8. Please furnish us the following information for issuance of policy. a) Previous insurance policy copy / Renewal
Notice b) NCB confirmation letter c) Copy of Registration certificate d) Copy of driving license Insurance.
9. Act 1938, Section 41- Prohibition of Rebates
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 or 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 or continuing a policy accept any rebate except such rebate as may allowed in accordance
with prospectus or tables of the Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine, which
may extend to five hundred rupees.

We look forward to having a happy and mutually beneficial partnership.

For & Behalf of
Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory
Date : 26-APR-2016 Reference No: REF74085513
From : RAVI Generated by : dipti.patel2202@general.bajajallianz.co.in

To,

Bajaj Allianz General Insurance Co. Ltd.

I/We acknowledge receipt of your Quote-cum-Proposal and accept the terms and intend to insure my/our vehicle
detailed therein with you. I/We agree that this Proposal and the declarations shall be the basis of the contract between
Bajaj Allianz and me/us. I/We confirm that the vehicle is being used for private purposes only. I/We warrant the truth
of the forgoing statements in every respect and agree that if I/We have made any false statement or provided false
information, the claim shall be repudiated and premium forfeited. I/We also declare that if any additions or alterations
are carried out after the submission of this Quote-cum-Proposal, then the same would be conveyed to Bajaj Allianz
immediately.

Please find attached my/our remittance of premium of Rs.15400/- by Cash/Cheque No__________

dated____________ drawn on______________________________________ towards issuance of the Policy with the
following additional information.

Registration No: _______________ Engine No : _______________ Chassis No: _______________

Pin Code : 380060 Vehicle Make : HYUNDAI Vehicle Model : i 20

Sub Type : 1.2 MAGNA (O) Fuel : Petrol Registration Date : 29-APR-2015

NCB : 0% Total IDV : Rs.451338/- Voluntary Excess: 0

Proposed Insurance commencement date : 30-APR-2016 Policy Expiry Date : 29-APR-2017

Please mention your Name, Mobile Number and Reference Number on the reverse of cheque.

Date : ___________________ Signature of Proposer : ____________________