Go Digit General Insurance Ltd.
Proposal Form
Digit Private Car Package Policy UIN No.: IRDAN158P0005V01201718
Name ABDUL AABID Registration No. DL01CX2269
Partner Name Girnar Insurance Brokers Private Ltd
Address E 55 Okhla Vihar Jamia Nagar, South Delhi – 110025
Partner Code 1000087
Mobile xxxxxx0345 Partner Mobile No. +917551196989
Email axxxxxxxxx8@[Link] Partner Email support@[Link]
Aadhar No. -- For Claims, contact us at 1800-103-4448
ABOUT MY VEHICLE.
Registration No. DL01CX2269 Engine No. F8DN5882734 Chassis No. MA3EUA61S00B25226
Make MARUTI SUZUKI Model/Vehicle Variant (Sub-Type) ALTO 800/ VXi
Trailer Regn. No.* -- Year of Regn./Manufacturing 2017/ 2017 Colour* --
RISK I WANT TO COVER FOR.
From 02-Mar-2019 12:50:00
Period of Policy
To 01-Mar-2020 23:59:00
Coverages Opted Package Policy Invoice No. IA001684226
Compulsory Deductible
1000 Voluntary Deductible (₹) --
(₹)
Vehicle Basic IDV (₹) 250000 Additional Excess (₹)
IDV for Bi-fuel Kit* (₹) -- IDV for Electrical Accessories (₹) --
IDV for Non-Electrical Accessories
Parts Depreciation Protect(IRDAN158A0009V01201718)(Cover only 2 claims per --
Add-Ons opted (₹)
year)
Total IDV (₹) 250000
ADDITIONAL QUESTIONS THAT CAN REDUCE THE PREMIUM.
PAN No. Aadhar No. -- Odometer Reading (km) --
ABOUT MY X INSURER.
Your previous insurer
Previous Policy
Previous Insurer -- Previous Policy No. -- --
Expiry Date
NCB% in Expiring Policy 0 Any Own Damage Claim in the Expiring Policy NO
HOW I WANT TO PAY.
Cheque No./NEFT
Bank ICICI Bank Ltd -- Date --
Ref. No.
Amount (including
7543 GSTIN No. Unregistered GST State Code 7
applicable taxes) (₹)
1
VEHICLE USAGE AND REPAIR INFORMATION
Upto 3,000 km 3,001 - 6,000 km
Estimated Usage of the Vehicle During the Year
6,001 - 12,000 Km Above 12,000 km
In the Event of Claim, where would You prefer to Repair Your Any Workshop Digit Recommended Workshop Only
Vehicle
BY SHOWING INTEREST IN THE POLICY, YOU AGREE TO THE BELOW TERMS AND CONDITIONS.
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.
Break in Insurance: The policy is issued subject to acceptance of risk after evaluation of the Vehicle Inspection report. Own Damage cover (Section - I) would not
commence unless the satisfactory Vehicle Inspection report has been received by us. If the Company does not receive the Vehicle Inspection report or the report is
adverse, the Company, at its discretion, will cancel Policy as per the Motor Tariff
I/We further declare that I/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 as well as for Aadhaar/PAN authentication as per the regulatory requirement.
I/We hereby agree and undertake that I/we are agreeable not to receive the hard copy of the Policy and related documents
I/We hereby affirmatively warrant that the Assured named herein/owner of the vehicle insured holds a valid Pollution Under Control (PUC) Certificate on the date of
commencement of the Policy and the same has been shown to the agent/authorized person of intermediary. I further undertake to renew and maintain a valid and
effective PUC Certificate during the duration of the Policy period. If the PUC certificate is not found valid on the date of loss, I understand that the Company reserves
the right to cancel the policy.
I/We hereby undertake to inform the Company in case of change on account of addition of CNG/PNG kit and ensure endorsement in my policy.
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. Address: Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru, Karnataka 560095 | IRDAI Reg No.
158 CIN U66010PN2016PLC167410, GST Reg. No.: 29AACCO4128Q1ZW HSN: 9971/General Insurance Services, GSTIN Address: Bengaluru Retail Business
Centre, Atlantis No 95 4th B Cross Road 5th Block Koramangala Industrial layout, Bangalore, Karnataka, PIN-560095| Website: [Link]
2
Go Digit General Insurance Ltd. Proposal Deposit Receipt
Your rupees have arrived, safe and sound.
Receipt No. RA002753726
Receipt Date 02-Mar-2019
Received with thanks from: ABDUL AABID
Mode of Payment Instrument No. Instrument Date Amount (₹)
-- -- 7543
Issuance of this receipt does not amount to acceptance of the risk by Go Digit General Insurance Limited. The insurance cover
for the risk shall be as per the terms and conditions of the insurance contract and after the allocation of the receipt amount
against insurance contract.
For & On Behalf of Go Digit General Insurance Ltd.
Praveen Bhat
Vice President Customer Experience
[Link]@[Link]
Authorized Signatory
Printed, Signed, and Executed at Bengaluru
Go Digit General Insurance Ltd. Address: Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block,
Bengaluru, Karnataka 560095. IRDAI Reg No. 158 CIN U66010PN2016PLC167410, GST Reg. No.: , HSN: 9971/General
Insurance Services, GSTIN Address: Bengaluru Retail Business Centre, Atlantis No 95 4th B Cross Road 5th Block
Koramangala Industrial layout, Bangalore, Karnataka, PIN-560095
In case of claim or any other query, please contact our 24-hour Call Centre at 1800-103-4448, email us at hello@[Link],
or visit our website [Link].