Go Digit General Insurance Ltd.
Reference No: D180526173
DIGIT COMMERCIAL VEHICLE PACKAGE POLICY - PROPOSAL FORM / TRANSCRIPT
(Goods Carrying Vehicle)
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2 [Link] proposal will be the basis of the insurance policy that we issue. You must disclose all facts relevant to all person(s)/asset(s) proposed to be insured
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96 that may affect the Company’s decision to issue a policy or its terms. Non-compliance may result in avoidance of the policy.
759 [Link] there is insufficient space for you to provide information, whether as requested or otherwise, please attach a separate sheet duly signed or affixed with
thumb impression.
36 [Link] you are in doubt, you can get in touch with your agent/intermediary or call us at 1800 300 34448 or e-mail at hello@[Link]
9275
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50 * For Partner Use Only:
9575 Partner Code Sub Partner Code Partner Name
1178687 HDFC BANK LTD
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PERSONAL DETAILS
. 1) Proposer: Title Mr./Ms/Mrs. Name: DEVENDRA .
D *2) Are you an existing Go Digit General Insurance Ltd. Customer (Digit): Yes / No. If yes, please mention the Policy No:
*3) Date of Birth:( DDMMYY) ______________________ *4) PAN No _______________________________*5) UIDAI NO
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*6) GST Number
*7) Profession: Business / Govt Job / Doctor / Lawyer / IT professional / Office work / Field Job
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*8) Driving license issue year
1 8 a) Present Address: 379 UNBUJURG RAV MOHALLA UNBUJURG WEST NIMAR UN MADHYA PRADESH 451440,Khargone-451440
8 b) Mobile No xxxxxxxxx0078
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VECHILE DETAILS
*Registration No NEW Model DOST/XL BSVI *Vehicle IDV (Rs.) 845025
*Non-Electrical
Vehicle variant (sub
xx *Date of Registration -- DOST/XL BSVI Accessories IDV in
type)
N (Rs.)
*Electrical Accessories
Chassis No 19873E67 Fuel Type Diesel
IDV in (Rs.)
D Engine No 4228658 Wheels 4 Wheeler Goods Type Hazardous / Non-Hazardous
*CNG / LPG Kit IDV Go
Year of Manufacture --/2024 Permit Type Public Carrier
(Rs.)
D
*Trailer registration No GVW 2625 *Trailer IDV (Rs.)
Max. Licensed Seating
*Finance Details HDFC BANK LTD 2 Total IDV (Rs.) 8,45,025.00
8 Capacity
*Vehicle modified for *Vehicle Usage/Body
Make ASHOK LEYLAND Deck Body
2 Physically challenged Type
0
1
D Risk Coverage Details
30
*Voluntary Deductible
From 31-12-2024 11:21:02 0.00
/Additional Excess
4 Period of Insurance
84
To 30-12-2025 23:59:59 *Endorsement opted IMT-21,IMT-23,IMT-28,IMT-7
A
-- Coverage Package/TP + Fire &/OR Theft
AddOn Cover AddOn Coverage Details UIN
IRDAN158RP0001V01201819/A0035V01201
3-- Parts Depreciation Protect
Cover only 2 claims per year 920
N IRDAN158RP0001V01201819/A0040V01201
Additional Towing Expenses Sum Insured :- 5000
1 920
Details of the Nominee for Personal Accident Cover for Owner-Driver
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Appointee Appointee
Name Relation Age
Name relation
PREVIOUS INSURER DETAILS
*No of claims & claim
Company Name Policy No Policy Expiry Date NCB %
amount
0% 0
*PREMIUM PAYMENT DETAILS
Cheque No/NEFT Ref No Bank Name Date Amount (Including applicable taxes)
DECLARATION
· I/We, hereby declare that the statements and particulars given in this Proposal form are complete, true and accurate and I/We agree that the Insurance
company will not be liable under the insurance contract if it is found that any of my/our statements or particulars or declarations in this proposal form or
other documents are incorrect /misleading /Fraudulent in any respect on any matter to the grant of a cover or submission of claim in future.
· I/We hereby agree to receive all monies due from the company by way of refund of premium, claims etc. into my/our bank account / payment mode as
specified in the instrument / electronic transaction tendered towards insurance premium and such electronic transfer will constitute full and final discharge
of the Company’s obligation.
· I / We declare that the rate of NCB claimed by me/us is correct and that no claim as 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.
· I/We, hereby agree that in Case of Break in Insurance, the policy would be issued subject to acceptance of vehicle risk after evaluation of the pre-
inspection report. Third Party and Personal Accident for Owner Driver covers (Section - II/III/IV) will start immediately post risk inception date and time,
however OD cover (Section - I) would not commence unless satisfactory pre-inspection report has been received by the Company. If the Company does not
receive the pre-inspection report within 3 days from the issuance of policy, the own damage portion of the policy will be cancelled within 3 days from date
of issuance of policy. Accordingly, policy will be amended and balance premium will be refunded after retaining third party liability portion of the policy. If
the pre-inspection report is adverse, the Company, at its discretion, can amend or cancel the own damage portion. Accordingly, the policy will be amended
and balance premium, if any, will be refunded.
· I/We further declare that l/we will notify in writing any change in the details so furnished hereinabove occurring after the proposal has been submitted but
before communication of the risk acceptance by the Company.
· I/We authorize the Company to share information pertaining to my proposal for the sole purpose of proposal underwriting and/or claims settlement and
with any Governmental and/or Regulatory authority.
I/We hereby agree and undertake that I/we are agreeable not to receive the hard copy of the Policy and related documents Yes/No
Date:
Place:
Signature of the Proposer
Declaration from Person filling the form in case proposer is unable to sign or signs in vernacular:
I hereby certify that the contents of the proposal form and/or any other documents used towards solicitation have been fully explained to the Proposer and that
he/ she/they have fully understood the said contents. I hereby confirm that the responses have been recorded to the best of my ability.
Date:
Place: Signature (on behalf of the Proposer)
Name & Relationship with Proposer:
* Indicates optional fields
INSURANCE 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 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 renewing a policy accept any rebate, except such rebate as may be allowed in accordance with the published
prospectus or tables of the insurer. ANY PERSON MAKING FAULT IN COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE
WITH FINE WHICH MAY EXTEND TO TEN LAKHS RUPEES.
Go Digit General Insurance Ltd, A Company incorporated under Indian Companies Act, 2013 and licensed by Insurance Regulatory and Development
Authority of India [IRDAI] vide Reg No. 158, Corporate Identification Number U66010PN2016PLC167410, Address Atlantis, 95, 4th B Cross Road,
Koramangala Industrial Layout, 5th Block, Bengaluru 560095. Web
Additional Information for Bank purpose only
To be filled by Bank personnel
LG/Emp. Code SP Code SP Name LC Code LOS number: Quote number
M26228 M26228 M26228 158666282 D180526173
Own Damage Premium [A] (`) Liability Premium [B] (`)
Own Damage Premium (`) 838.64 Basic Third-Party Liability (`) 16049
Add-Ons Premium (`) 4,029.10
PA cover for Owner-Driver (`)
NCB Discount Amount (`) -0 330
Legal Liability to Paid Driver (Persons:1)(`) 50
50
Legal Liability to Paid Cleaner (Persons:1) (`)
Total OD (`) Total Liability Premium (`)
4,867.74 16,479.00
Premium
Net Premium [A+B] (`) 21,346.74
CGST @ 6% = (` ) + SGST/UTGST @ 6% = (` ) 1,925.88
CGST @ 9% = (` ) + SGST/UTGST @ 9% = (` ) 953.60
KFC @ 1% (`) 0.00
Total Premium (`) 24,226.22
Declaration
1.I hereby agree to purchase Digit Commercial Vehicle Package Policy (Goods Carrying Vehicle) , UIN: IRDAN158RP0001V01201819 from HDFC Bank
Limited (Corporate Agent of Go Digit General Insurance Limited)
2.I / we hereby agree to confirm within 30 days from issuance of policy in case of any objection or disagreement with the above. I hereby further agree
that submission of proposal and payment of premium does not automatically fasten the risk on the Company and the assumption of risk by Company shall
arise only upon company expressly in writing underwrites the proposal and intimates to me/ us.
3.I hereby agree to avail IMT 7** endorsement.
4.I agree that payment of premium for above policies shall be deducted from my Loan Account as availed by me from HDFC Bank Limited.
[Link] view detailed terms and conditions, please refer [Link]
6.I hereby declare that I have read the policy Terms and Conditions carefully.
7.I/We understand that the insurance plan being opted by me / us is purely on voluntary basis and is in no way linked to granting of the loan / OD / line of
credit by HDFC Bank.
Date: Place: Authorized Signatory:
**IMT 7 It is hereby declared and agreed that the vehicle insured is hypothecated with HDFC Bank Pvt. Ltd. and it is further understood and agreed that the
Pledgee is interested in any monies which but for this Endorsement would be payable to the insured under this policy in respect of such loss or damage to the
vehicle insured as cannot be made good by repair and / or replacement of parts and such monies shall be paid to the Pledgee as long as they are the Pledgee
of the vehicle insured and their receipt shall be a full and final discharge to the insurer in respect of such loss or damage. It is further declared and agreed that
for the purpose of the Personal Accident Cover for the owner-driver granted under this policy, the insured named in the policy will continue to be deemed as the
owner-driver subject to compliance of provisions of the policy relating to this cover. Save as by this Endorsement expressly agreed that nothing herein shall
modify or affect the rights or liabilities of the Insured or the Insurer respectively under or in connection with this Policy or any term, provision or condition thereof.
Subject otherwise to the terms exceptions conditions and limitations of this policy.
For & On Behalf of Go Digit General Insurance Ltd.
Praveen Bhat
Senior Vice President - Customer Experience
[Link]@[Link]
Authorized Signatory
Printed, Signed, and Executed at Bengaluru
Consolidated Stamp Duty has been paid as per Letter
of Authorization No.67-B/04/2017-18 Date: 30th May
2017 issued by Department of Stamps and
Registration , Bengaluru- 560009 - KARNATAKA.
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