12/27/2017 202.131.96.98:8099/QuotaionMaster/PrintQuotation?

hdnQTNumber=1533069

Quota on Cum Proposal Premium

Commercial - Passanger Carrying Not Exceed 6 Pax
Rs. 21129
MUM-0511569-01-R-1 30-DEC-2017

1a Travels And Tours Gst No :

Shop No 2 And A Navin Shopping Center Bha pada Cross Bhandup West, Mumbai,

Nom. Det. - Name: Rela on: Age:

Insp. Ref. No : Insp. Dt. & Time : Agency Name :

Vehicle Detail
Vehicle : Honda - Amaze - 1.5 E Mt I-Dtec [Diesel]
IDV : 575427 | Sea ng Capacity : 5 | Reg.No : MH03BC5610
Engine No. : N15A13018200 | Chassis No. : MAKDF25GJFN110499
C.C : 1498 | YOM : 2015
Add-On's Opted: None
Hypotheca on : None

Own Damage Sec on Liability Sec on

Basic Premium (Zone - A) 6944 Third Party (C.C:1498) 8408
Electric Accessories 0 T.P. of Gas Kit/Pass.(0+4140) 4140
Non Electric Accessories 0 Unnamed Passanger (5) 0
GAS Kit 0 Owner Driver (Individual) 100
Add Od/Gvw 0 Legal Liability to Driver 50
IMT 23 0 Total Liability [C] 12698
Overturning 0 Loading Amount (0%) [D] 0
NCB (25%)(Claim-No) 1736 Package Premium [A+B+C+D] 17906
Total OD (T.D.:65%) [A] 5208 G.S.T. (18%) 3223
Add-On [B] 0 Net Premium 21129
RELIANCE GENERAL INSURANCE CO LTD
Add On's Not Opted : Nil Dep., Consumable, Engine Cover, Tyre, NCB Protector, Return To Invoice, Key Cover, RSA, L.O.P.B., E.T. & H.E.

NCB :- The NCB declared above is true and correct. I/We understand that in the event the NCB declaration provided by me above, is/are found to be incorrect later on, all the benefits under the policy, will stand forfeited and no claim
will be payable under OD section.
Exclusive Mandate :- I/We hereby authorize/mandate Landmark Insurance Brokers Pvt. Ltd., (“LIBPL”) to represent me/us as my/our insurance broker, for my/our insurance need(s) and you can contact me/us for providing any
updates, information etc., from time to time, even though I/we may be registered under the DND.
Duty of Disclosure :- I/We have carefully checked/reviewed the details in the above quote/proposal form and state that the information provided in the quotation/ proposal form, is/are true and correct and nothing material has
been concealed therefrom. After satisfying myself/our-self with the terms, features, benefits etc., of the insurance policy, I/We have opted for taking the insurance policy from the said/listed insurance company and authorize you to
forward my/our details/information to the insurance company. I/We understand that any information provided by me/us, if later on found to be incorrect/incomplete by the insurance company, will have an impact on the premium
amount, underwriting of the risk and/or claims settlement by the insurance company. I/We understand that you are only acting as a facilitator/conduit in the above transaction. Any underwriting decision, issuance of policy and
settlement of claim is the sole right of the insurance company and your company does not have any role/right to carry out the above acts.
Grievance/Concern :- In case of any grievance/concern relating to the above/policy document (including non-receipt of policy document), LIBPL shall use its good efforts to resolve the same at the earliest by engaging with the
insurance company. You can reach us on our Toll Free No. 1800-419-419-9 or write to us at customercare@policyboss.com. Any dispute arising between the parties (you, us and insurance company) shall at the first instance be
resolved through mutual conciliation, failing which courts at Mumbai shall have exclusive jurisdiction to resolve any such disputes.
Green Ini a ve :- I would like to contribute to the green initiative of the Govt. of India and would like to receive the policy document in soft-copy/as e-policy copy,on the email id provided above (if any).

Toll Free No. 1800-419-419-9 9:30 a.m. to 6:30 p.m.(Monday to Saturday) Signature of Registered Owner
Tear it from here
Contact Us : Gayatri Kukreja 100559

Dispatch Add : Shop No 2 And A Navin Shopping Center Bha pada Cross Bhandup West
Chq. Col. Add :
Customer Details : 9594353262 nd1711@gmail.com
0221003116P113001299|UNITED|20|639364| P : 22600 Ref. Code 27-Dec-2017 14:49 PM[100559]

http://202.131.96.98:8099/QuotaionMaster/PrintQuotation?hdnQTNumber=1533069 1/1