COMMERCIAL VEHICLE

(GOODS CARRYING, MISCELLANEOUS & SPECIAL TYPES OF VEHICLES)

PROPOSAL FORM
Name of Intermediary : Policybazaar Insurance Brokers Pvt Ltd. AG Code: AG043210 Proposal No. QVNPG3259070

IMPORTANT The details provided in this proposal form is based on the details as shared by you to Policybazaar Insurance Brokers Pvt Ltd. and is factually
correct.
❖ The liability of the Company does not commence until the Company has accepted the Proposal Form dully filled in all respects and the full premium is paid.
For any clarification on the cover, terms, etc., please log on to www.royalsundaram.in or you may write to us at [email protected]

ABOUT YOURSELF
Title Mr. Mrs. Miss Others (please specify) Mr.
Name: JAGDISH MENARIYA
First Name Middle Name Last Name

Date of birth: 15/05/1986 Are you Married? Yes No

Permanent S/O LAXMI LAL JI 12 VIJAYPURA VALLABHANGAR
Address

City: BALATHAL
State: RJ
Pincode: 313601
Communication VIJAYPURA BALATHAL VALLABHNAGAR
Address UDAIPUR

City: UDAIPUR
State: RAJASTHAN Pincode: 313601
Daytime Phone(s):
Mobile No. : XXXXXX2106
STD CODE

KYC Documents (Mandatory)

Pan FORM60 PAN No. : XXXXXX158N DOB : 15-05-1986 CKYC Number : XXXXXXXXXX9546
(For Individual Customer) (For Corporate Customer)
Driving License No Passport No Aadhar Number
Principal Officer
Name as per Aadhar Passport File No
Name as per Aadhar
Aadhar Number Registration Certificate Power of Attorney to transact business
Certificate of Incorporation and Memorandum & Article of Association
Any official document identifies partners/trustee/Foundations
Voter ID Card No NREGA Job Card
Please Specify_____________________________
Resolution of Board of directors to open account/
Mobile/Telephone Bill Bank Passbook/Account Statement
Resolution of managing body of the foundations/Association
Partnership/Trust deed
Electricity Bill Ration Card Employer Certificate
PAN allotment letter
Lease Agreement with Letter from any Public
Rent Receipt Authority or from UIDAI
Activity proof 1(for sole proprietorship only)
Activity proof 2(for sole proprietorship only)
Others Please Specify__________________ Others Please Specify__________________
E-mail: D************6@G***L.COM
Occupation: Please tick against the applicable description, if you fall under any of the below listed categories. If you fall under more than one of the
listed titles below, please tick against all the applicable heads.
Low Risk Category
Pvt. Sector Govt. Employee Self Employed RS Employee Head of the state or Government Employee - IT or ITES
Sports Persons SeniorGovernment/judicial/Military Officer Senior Executives of State - Owned Corporations Student
Retired Employee Company Owned Others (Please Specify)
High Risk Category
Film Industry Real Estate Senior Politician Important Political Party Official House Wife Jewelry Proprietor
Chit fund Proprietor Bullion Dealers Trust,Charities,NGO with Foreign Funding Others (Please Specify)

AADHAR NUMBER
a) For Individual Customer:

Name as per Aadhar :

Aadhar Number : XXXX-XXXX- Date of birth of Insured : Gender :
b) For Corporate Customer:

Principal Officer
Name as per Aadhar :
Aadhar Number : Date of birth of Insured : Gender :
GST NUMBER
Name as per
GST Certificate :

Registered
GST Number :

Address as per
GST Certificate :
District and State
as per GST Certificate :

ELECTRONIC INSURANCE ACCOUNT(EIA) NUMBER

Do you have Electronic Insurance Account Yes No (If yes please provide)

Account No :
Repository Name :
Nominee Name :

Nominee Age : Nominee Relationship :

ABOUT YOUR BANK DETAILS Please attach a copy of cancelled cheque for verification of details, remittance of claim payment/refund if any.
Bank Name: Branch:
Type of Account: Saving Current Account No:
IFSC Code: MICR Code:
Customers are requested to remit the premium by way of cheque or demand draft or credit card. Cash remittance to be avoided.

UIN - IRDAN102P0005V02201617/IRDAN102P0006V02201617 Commercial Vehicle Proposal Form

 ABOUT YOUR VEHICLE Please give full details:
Address as per Vijaypura balathal vallabhnagar Fastag _________________________________
Registration Certificate : UDAIPUR

City: MORADABAD
State: Uttar Pradesh Pincode: 313601
Registration No. : UP21BN5190 Type of body : DELIVERY VAN

Engine No. : XXXXXX5841 Seating Capacity : 2

Chassis No. : XXXXXXXXXXXXX3340 Type of Permit : National/Zonal/Hilly Areas

Make & Model : MAHINDRA, BOLERO MAXITRUCK PLUS Date of Registration : 19/10/2016
BS-4 - 2 Seater

Registering Authority : MORADABAD Current ownership New Vehicle Used Vehicle

Year of Manufacture : 2016 Type of Fuel Petrol Diesel CNG LPG

Cubic Capacity : 1196 Others___________________________(please specify)
Gross Vehicle Weight : 1585
Period of Insurance: From : 23/09/2024 To : 22/09/2025
USAGE OF THE VEHICLE
State clearly the purpose(s) for which the vehicle will be used: i) Explosives such as nitro glycerine, dynamite, fireworks or any
1) The Vehicle will be used solely for carrying your own goods other similar explosive. ii) Liquefied petroleum or gasoline.
iii) Chemicals. iv) Gases in liquid, compressed or gaseous form
YES NO
v) Other goods of a hazardous nature
2) The Vehicle is not licensed for road use and will be used solely at your
premises or only on sites to which the public has no right of access YES NO
If 'Yes' state the nature of the goods carried and frequency for this use
YES NO
3) Area of usage of vehicle ____________________________________________________________
4) Will the vehicle be used to transport: ____________________________________________________________
INSURED DECLARED VALUE OF THE VEHICLE & ANY ACCESSORIES
Vehicle* Non-electrical accessories Electrical & Electronic Value of CNG/LPG Kit Total
fitted to the vehicle accessories fitted to the vehicle
248,296.00 0.00 0.00 0.00 248,296.00
Note :
The Insured's Declared Value (IDV) of the vehicle will be deemed to be the 'SUM INSURED' for the purpose of this Policy which is fixed at the commencement of each
Period of Insurance for the insured vehicle.
The IDV of the vehicle (and side car/accessories, if any, fitted to the vehicle) is to be fixed on the basis of the manufacturer's listed selling price of the brand and model as
the insured vehicle at the commencement of insurance/renewal and adjusted for depreciation (as per schedule below).
The insured vehicle shall be treated as CTL if the aggregate cost of retrieval and/or repair of the vehicle, subject to Terms and Conditions of the Policy, exceeds 75%
of the IDV of the vehicle.

Age of Vehicle % of Depreciation for fixing IDV not exceeding 6 months

Exceeding 6 months 5%
Exceeding 6 months but not exceeding 1 year 15%
Exceeding 1 year but not exceeding 2 years 20%
Exceeding 2 years but not exceeding 3 years 30%
Exceeding 3 years but not exceeding 4 years 40%
Exceeding 4 years but not exceeding 5 years 50%
(Please tick appropriate)
1. Is the vehicle financed?
Hire Purchase Hypothecation Lease Name and Address of finance company: _________________________________________________
2. Is the vehicle fitted with an anti-theft device approved by Automobile Research Association of India(ARAI), Pune and the installation certified by a
recognized Automobile Association? Yes No
If 'Yes' attach full details, including copies of by purchase & installation and Automobile Association approval documents.
3. Is there any other Safety features installed in your vehicle? ABS Airbags Others (Please Specify)________________________________________
4. Whether the vehicle is driven by non-conventional source of power? Yes No
If 'Yes' please give details____________________________________________________________________________________________________________
5. Whether the vehicle is used for driving tuitions? Yes No
If 'Yes' please give details____________________________________________________________________________________________________________
6. Whether extension of geographical area to the following countries required ? Yes No
Bangladesh, Bhutan, Maldives, Nepal, Pakistan and Sri Lanka.
If 'Yes' state the name of the countries 1)______________________________2)_______________________________3)________________________________
7. Whether use of vehicle is limited to own premises? Yes No
8. Whether the commercial vehicle is also used for Private purposes(excluding use for hire or reward )? Yes No
9. Whether vehicle belongs to foreign embassy / consulate ? Yes No
10. Whether vehicle is designed for use of Blind/ Handicapped/ mentally challenged persons and duly endorsed as such by RTA ? Yes No
11. Whether the vehicle is fitted with fibre glass tank ? Yes No
UIN - IRDAN102P0005V02201617/IRDAN102P0006V02201617 Commercial Vehicle Proposal Form
BENEFITS UNDER OUR POLICY:
• Registered owner has valid driving license Yes No
• Additional Towing charges of
(a) 1000 or multiples of 1000 upto 20000 opted for over and above the limit prescribed in the policy.
(b) 250 or multiples of 250 upto 1500 opted for over and above the limit prescribed in the policy (for three wheeled vehicles).
If you wish to include this cover, state the limits required ______________________
ADD-ON COVERS
Depreciation Waiver Clause Would you like the Depreciation applicable on parts to be waived, in case of a partial loss claim. Yes No
Windshield Glass Clause In the event of Breakage of Windshield Glass, would you like to avail replacement without affecting
your No Claim Bonus Yes No
Enhanced PA Cover Would you like to opt for Enhanced PA Cover? Yes No
What limit would you like to opt for PA to Owner-Driver( )_________
What limit would you like to opt for PA to Paid Driver/Conductor/Cleaner( )______________

EMI Protector Clause Would you like to opt for EMI Protection cover for your vehicle in case of partial claims? Yes No
If yes, what limit you would like to opt for EMI Protector cover Rs.0.00

Would you like to opt for EMI Protection cover during Total loss/Theft also? Yes No
Loss of Income Clause Would you like to opt for Loss of Income cover for your vehicle in case of partial claims? Yes No
Limit Opted (In Rs.) Time Duration opted
0.00

Would you like to opt for Loss of Income cover during Total Loss/Theft also? Yes No
• Do you wish to cover damage caused to the unit by overturning during operational use as a Tool of Trade (Applicable Yes No
for Miscellaneous & Special Types of Vehicles only)?
• Do you want to cover for lamps/tyres/tubes mudguards bonnet/side parts bumpers etc as per IMT 23 Yes No
LIABILITY TO THIRD PARTIES
The policy provides Third Party Property Damage (TPPD) of 7.5 lakh. Do you wish to opt for statutory TPPD liability coverage of 6000/- only. Yes No

Do you wish to cover legal liability to a) Paid Driver/Conductor/Cleaner Yes No

If 'Yes' number of persons ___________________________________________________ (Maximum restricted to seating capacity)

b)Non-fare paying passenger Yes No if yes number of persons _________________________________________________________________________

PERSONAL ACCIDENT (PA) COVER
• Compulsory Personal Accident (CPA) Cover For Owner Driver Yes No
If No, Tick any of the three options

Registered owner does not have valid Driving License.

Registered owner having CPA cover with other motor policies.

Registered owner having PA cover of Rs.15 lakhs and above.

• Do you wish to include PA cover for Paid Driver/Conductor/Cleaner? Yes No
If yes, give the number of persons and Capital Sum Insured (CSI) opted. The maximum CSI available per person is 2,00,000/-
Number of Persons CSI Oped ( )

0 0

PREVIOUS HISTORY
1. Is the vehicle in a roadworthy condition and free from damage? Yes No If 'No' please give full details
If 'No' please give full details:_____________________________________________________________________________________________________________
2. Name and address of the previous insurer GO DIGIT INSURANCE LIMITED,Vijaypura balathal vallabhnagar
3. Previous Policy No. 39010231 Policy period 22-Sep-24
4. Type of cover Liability only cover Package cover Others (specify)__________________________________________________
5.Add on covers in previous policy:
6. Has any insurance company ever:
a) Declined the proposal Yes No
b) Cancelled & refused to renew Yes No
(If 'Yes' reasons there of ____________________________________________________________________________________________
c) Imposed special condition or excess Yes No
(If 'Yes' reasons there of ____________________________________________________________________________________________
DECLARATION - NO CLAIM BONUS
Are you entitled to No Claim Bonus Yes No (If 'Yes' please submit proof from your previous insurer.)
I hereby declare that I have not made claim (or) I have made claim under my previous Policy No 39010231 issued by GO DIGIT
INSURANCE LIMITEDI/We declare that the rate of NCB of 25% claimed by me/us is correct and that no claim has arisen in the expiring policy
period (copy of the policy enclosed). I/We further undertake that if this declaration is found to be incorrect, all benefits under the policy in respect
of Section I of the Policy will stand forfeited.

UIN - IRDAN102P0005V02201617/IRDAN102P0006V02201617 Commercial Vehicle Proposal Form

 Does the vehicle have valid Pollution Under Control (PUC) Certificate? Yes No
PUC Number: ________________________________
PUC Expiry Date: ________________________________
*"In line with the Central Motor Vehicle Act, 1989 and as per the directive of Hon'ble Supreme Court of India, it is mandated that insured must produce a valid "Pollution Under control" Certificate as and when asked by
the insurer and it is the responsibility of the insured to renew the same before expiry of the validity of the PUC certificate. Absence of Valid certificate may lead to cancellation of insurance"

PAYMENT DETAILS: Please tick (✓) payment option

Cheque/DD Number ___________________________________________ Credit Card Debit Card Payzaap Paytm Bill Desk

Bank ____________________________________________________________________________________________________________________________

NEFT RS Account No ________________________________ Transaction Ref No ___________________________________________________

Date ____________________ Amount ________________________________ Cash Amount ___________________________________

*Payment must be made favouring Royal Sundaram General Insurance Co. Limited
Authorization for electronic policy fulfilment and service communication(Please read carefully and put a check mark against each before signing)

I hereby consent that the proposal status,policy details and renewal reminders may be sent to me by email and SMS.

I hereby consent to and authorize Royal Sundaram General Insurance Co.Limited(Company)to make welcome calls,service calls or any other communication
(electronic or otherwise)with respect to the proposed or existing policy of Company from time to time.

We hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or through telephonic / email / web-
inputs means or other means, as updated from time to time within group entities.

AML Guidelines- Declaration of Insured

I/we hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been/will be paid out of proceeds of crime related
to any of the offence listed in Prevention of Money Laundering Act, 2002.

I understand that the Company has the right to call for documents to establish sources of funds.

The insurance company has right to cancel the insurance contract in case I am/ have been found guilty by any competent court of law under any of the statutes,
directly or indirectly governing the prevention of money laundering in India.

I hereby authorize Royal Sundaram General Insurance Co. Limited to upload/download the required KYC documents pertaining to me in/from the CKYC
portal.

PREMIUM COMPUTATION SUMMARY

Basic OD Premium 1,349.74 Basic TP 15,849.00

Other OD Covers 0.00 Other TP Covers 0
Total TP Premium 15,849.00
NCB(25%) : 337.44 Total OD + TP Premium 16,861.30
Add on Premium 0 IGST : 2,084.04
Total OD Premium 1,012.30 Premium inclusive of GST 18,945.04

COMPULSORY DEDUCTIBLE
The Policy excludes the first portion of each claim for loss or damage to the Motor Car. The amount of the Deductible is Rs.500.
DECLARATION
Before signing the Declaration check your answers carefully, particularly if this Proposal Form was completed by another person on your behalf.
I/we declare that to the best of my/our knowledge and belief the answers given are true and all material information has been disclosed.
I/we agree that if any answers have been completed by any other person such person shall for that purpose be regarded as my/our agent and acting on my/our behalf and not the agent of
Royal Sundaram General Insurance Co. Limited.
I/we declare that this Proposal Form is for insurance in the normal terms and conditions of the Insurer's Policy and shall be incorporated in and form part of the insurance contract.
• If any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the Insurers immediately
• It is an offence under the Motor Vehicles Act 1988 to make a false statement or withhold any material information for the purpose of obtaining a Certificate of Motor Insurance.
• Attach any other information material to the risk proposed
Place: UDAIPUR
Date: 22/09/2024 *Signature of the proposer (Vehicle Owner)
This proposal form is electronically signed by the proposer by way of
validating One Time Password(OTP) send to his/her registered mobile number

SECTION - 41 OF INSURANCE ACT 1938 - PROHIBITION OF REBATES

1. 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
of 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 continuing the policy accept anyrebate except such rebate as may be allowed in accordance with the published p rospectus or tables of the Insurer.
2. If any person fails to comply with sub-regulation (1) above, he shall be liable to payment of a fine which may extend to Ten Lakh Rupees.
Dear Customer, Thank you for choosing Royal Sundaram as the Insurer of your vehicle.We are delighted to have you as our customer. Please find enclosed Commercial
Quote No.QVNPG3259070 which has been issued based on the details submitted to us by the Insurance Broker - Policybazaar Insurance Brokers Pvt Ltd.. The details
provided in this proposal form is based on the details as shared by you to Policybazaar Insurance Brokers Pvt Ltd. and is factually correct.
 Royal Sundaram General Insurance Co. Limited
(Formerly known as Royal Sundaram Alliance Insurance Company Limited)
Corporate Office:Vishranthi Melaram Towers, No.2/319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai-600097.Registered Office: 21, Patullos Road, Chennai - 600 002
Royal Sundaram IRDAI Registration No.102 | CIN:U67200TN2000PLC045611

✆ 1860 425 0000 | 1860 258 0000 ✉ [email protected] | www.royalsundaram.in

Passenger Carrying UIN: IRDAN102P0007V02201617 | Goods Carrying UIN: IRDAN102P0005V02201617 | Miscellaneous Vehicle UIN: IRDAN102P0006V02201617 PR18325/APRIL19

UIN - IRDAN102P0005V02201617/IRDAN102P0006V02201617 Commercial Vehicle Proposal Form