Proposal cum Acknowledgement Page

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CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

PROPOSAL FORM CUM PAYMENT
ACKNOWLEDGEMENT
Issuing Office Address :
AHMEDABAD - BRANCH
OPTIONZ,2ND FLOOR,
OPP HOTEL NEST,S.P COLONY, OFF C G ROAD,
AMBAWADI VISTAR S.O
AHMEDABAD
GUJARAT
PIN-380015

: 3362143515503
Proposal Type : Market Renewal
Type of vehicle : Private Car
Agent Code
: 201570367334

Proposal No

1.Name of the Insured SATISHKUMAR WAZIRSINGH SAROHA

Vehicle Registration Address
Area
City
State
Pincode
Financier Type: Hypothecation

A 28 NARSHI NAGARA OPP BALIYADEV MANDIR LAMBHA GAM

NAROL S.O
AHMEDABAD
GUJARAT
382405
Financier Name: MAHINDRA AND MAHINDRA FINANCIAL SERVICES LIMITED

2.Registration Mark,Number and Description of the Vehicle Insured.

Date of Registration 25 Feb 2015

Registration No.
Engine No.

EAST AHMEDABAD
129968

Make

MARUTI

Cubic
Capacity

Year of
Manufacture

GJ-27-AH-3845
Place of Registration
7072132
Chassis No.
CIAZ - VXI
Model
Variant
VXI PLUS
PLUS
Gross
Vehicle
Weight
(GVW)
in kilos

Type of
Body

SALOON

Fuel Used

PETROL

Licensed Carrying Capacity

Public /
Private
Carrier

Licensed
Passenger
Carrying Capacity

Driver and Others

Total Seating
Capacity
Including Driver

2015
0
1
3.Effective Date & Time of Commencement of Insurance for the purpose of the Act.
From
14 Feb 2016 00:01 Hrs
4.Date of Expiry of Insurance To Midnight of 13 Feb 2017
Value of Chassis(Rs.)
Value of Body(Rs.)
For Vehicle(Rs.)
For trailer(Rs.)
Value of CNG/LPG (Rs.)
0.00
0.00
602,000.00
0.00
0.00
Non Electrical Accessories (Rs.)
Electrical / Electronic Accessories (Rs.)
Total Value (Rs.)
0.00
0.00
602,000.00
PREVIOUS INSURANCE PARTICULARS(If Applicable)
Name of Previous Insurer : NEW INDIA
Policy No: 31260031140302399479
Period From : 14 Feb 2015
Type of Earlier Policy

To: 13 Feb 2016

Comprehensive Package

Past Claims History

Number of Claims Made

Claim Paid Amount (Rs.)
Are you entitled for No Claims Bonus(NCB)

Previous Policy
1
1.00
No

LIMITATIONS AS TO USE :
The Policy covers use of the vehicle for any purpose other than: a)
Hire or Reward b) Carriage of goods (other than samples or
personal luggage) c) Organized racing d) Pace making e) Speed
testing f) Reliability Trials g) Use in connection with motor trade.

Benefit No.

Name of the Cover Opted

Waiver of Reduction in Depreciation

If Yes,then NCB %

DRIVER:
Any person including 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 Vehicles Rules 1989.

Discount

Additional Premium
0.00

1,505.00

EMI Protection Cover

Coverage for Disabled vehicle
Daily cash allowance
Net Premium

(Rs.)

Service Tax Including Cess (Rs.)

13,385.00
1,941.00

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Total Premium (Rs.)

15,326.00

IMT Nos:22,28,16,7
Applicable benefits
Warranty
Special Conditions
Compulsory Excess (Rs.)

1,000.00

Additional Imposed Excess (Rs.)

Issuing Office Address :

AHMEDABAD - BRANCH
OPTIONZ,2ND FLOOR,
OPP HOTEL NEST,S.P COLONY, OFF C G ROAD,
AMBAWADI VISTAR S.O
AHMEDABAD
GUJARAT
PIN-380015

: 3362143515503
Proposal Type : Market Renewal
Type of vehicle : Private Car
Agent Code
: 201570367334

Proposal No

NOMINEE DETAILS :
S.No Name of the Nominee RelationShip Age of the Nominee % of Share Name of the Guardian
1

SUNITA

Date of Issue

25 Jan 2016

Wife

32
Time

Relationship With Guardian

100
13:31 Hrs

Place:

AHMEDABAD - BRANCH

Regd & H.O: "Dare House" 2nd Floor, 234 N.S.C Bose Road, Chennai 600 001 E-mail
Customercare@Cholams.Murugappa.com
For more Information: Contact on Cholamandalam MS Toll-Free 24 hours Helpline at 1800-200-55-44: Web:
www.cholainsurance.com
Declaration:
I/ We have remitted an amount of Rs.15326/- (Rupees) to vide Cheque/DD No. 224021 dated 19/01/2016 in favour of M/s
Cholamandalam MS General Insurance Company Limited (Chola MS) drawn on Bank towards premium to avail insurance for my / our
vehicle bearing No.GJ-27-AH-3845.
The terms and conditions of the insurance policy have been explained by the Intermediary and understood by me/us.
I/We acknowledge that this is only an E-Proposal and acceptance of the same is subject to approval by the company and realization of
the premium cheque. In the event of non-realization of premium cheque due to any reason, proposal is deemed to be cancelled from
inception. I /We will not hold Chola MS responsible for any liability of whatsoever nature.
I / We hereby declare that the statements made by me / us in the proposal form are true and complete to the best of my / our
knowledge and belief. I / We hereby agree that this declaration shall form the basis of the contract between me / us and the
company. I / We also declare that if any alteration / addition is carried out after the submission of this proposal; the same shall be
conveyed to the Company immediately. I / We are aware that mere remittance of payment does not guarantee acceptance of this
risk, which decision shall be made by the Company. I / We agree to the Company taking appropriate measures to capture the voice
log for all such telephonic transaction carried out by me / us in accordance with procedures / regulations, internal or external. This
cover is valid in India only.
Declaration for No Claim Bonus (NCB)*(if NCB confirmation is not submitted but NCB claimed).
I /We declare that the rate of NCB of 0 % claimed by me/us is correct and that NO CLAIM has arisen in the expiring Policy Period
(Copy of Policy enclosed). I/We further undertake that if this declaration is found incorrect, all benefits under the Policy in respect of
Section - 1 (own damage) of the Policy will stand forfeited.
Signature of the Proposer:

Date:

Place:

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