1. Premium Details
Net Premium
Service Tax (12% of Net
Premium)
Education Cess(2% of
Service Tax)
Secondary and Higher
Education Cess
(1% ofService Tax)
Total Premium
Policy Premium(Including
all previous
Endorsement/s)
33984.40 4078.13 81.56 40.78 38184.87
Premium relating to this
Endorsement
50.00 6.00 0.12 0.06 56.18
Final Premium
after Endorsement
34034.40 4084.13 81.68 40.84 38241.05
Reliance Motor GCV A1 - PKG Public Other than 3W Endorsement Schedule
Policy Issuing Office:
Reliance General Insurance Co. Ltd.,
570, Naigaum Cross Road,
Next to Royal Industrial Estate,
Wadala (W), Mumbai – 400031
Policy Servicing Branch Office:
Gandhidham,KACHCHH
GUJARAT 370201
BBZ, S41, 12B, Above Shikar Puri Street, Main Market
Reliance General Insurance Co. Ltd,
Name of the Insured Mr JAYDEV B AYACHI
Correspondence Address of the Insured
GUJARAT - 370140
India
VILL SAMAKHIYALI
TAL BHACHAU BHACHAU
Policy No: 1103542334001520 Policy Period:From 17/06/2014 to 16/06/2015
Endorsement No. 72001
Endorsement Effective Date: 10/10/2014
Type of Endorsement: Additional
Service Tax Reg.No. AABCR 6747 BST 001
Category-General Insurance Business Service 00440005
In witness whereof this policy has been signed at BHACHAU on 10/10/2014. For any assistance with claims, please contact us on 1800 3009 (toll free) or email us at
services.rgicl@rcap.co.in
For and on behalf of Reliance General Insurance Company Limited
Authorized Signatory
Note: In the event of dishonor of the cheque, this endorsement automatically stands cancelled from inception, irrespective of whether a separate communication is sent or not.
Intermediary Name &
Code
11A18382 / AMARPREET KAUR SAINI
Intermediary Contact
No:
9321707654
Not withstanding anything to the contrary contained in the policy, it is hereby declared and agreed that Vehicle has been transferred From Personal Client JIWAN ROADLINES
To Personal Client JAYDEV B AYACHI. .All other terms and conditions of the policy remain unchanged.
Subject otherwise to terms, exclusions, conditions, limitations and warranties of the Policy.
Vehicle Make Vehicle Model Engine No./Chassis No. Registration Number
TATA 4018 AL 76563 / 11065 MH06AC4225
Registered Office: Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate ,Mumbai - 400 001
General Insurance

2. Address Of Issuing Office:
Reliance General Insurance Co. Ltd,
570, Rectifier House, Naigaum Cross Road,
Wadala (W), Mumbai – 400 031, India
Address Of Servicing Branch Office:
Gandhidham,KACHCHH
GUJARAT 370201
BBZ, S41, 12B, Above Shikar Puri Street, Main Market
Reliance General Insurance Co. Ltd,
Reliance Motor GCV A1 - PKG Public Other than 3W Policy Schedule
Schedule cum Certificate of Insurance
Name of the Insured :Mr JAYDEV B AYACHI Business Or Occupation:Business
Address of the Insured:
VILL SAMAKHIYALI
TAL BHACHAU
BHACHAU - 370140, GUJARAT
India
Tel .No .: Res.:
Effective date of commencement of insurance of the purpose of Act:Jun 17 2014 12:00AM
Period of Insurance: From 10/10/2014Hrs on 17/06/2014 to mid-night on 16/06/2015
Endorsement Effective Date: 10/10/2014
Particilars Of Vehicles Insured : Certificate No. :
Name of Registration Authority :PEN Geographical Area:
Limitations As To Use Persons or Classes of Persons entitled to drive:
The Policy covers use for any purpose other than:
a. Hire or Reward
Any person including the 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.
b. Carriage of goods (other than samples or personal luggage)
c. Organised racing
d. Pacemaking
e. Speed testing
f. Reliability trials
g. Any purpose in connection with Motor Trade
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 Rules 3 of the Central Motor
Vehicles Rules, 1989.
Limits of Liability:
As per requirements of Motor Vehicle Act, 1988
a. Under Section II-1 ( i ) of the Policy –Death of or bodily injury such amount as is necessary to meet there requirements of the Motor Vehicle Act, 1988
b. Under Section II (1 ) (ii ) of the Policy-Damage of Third Party Property Rs. 0
Deductible under Section-I - Rs. 1500
Voluntary Deductible under Section-I - Rs. 0
PA Cover for owner-driver under section 3 CSI Rs. 200000
Additional Excess Rs. 0
I/We hereby certify that the Policy to which this certificate relates as well as this certificate of insurance are issued in accordance with the provision of Chapter X and Chapter XI
of M.V.Act, 1988.
*Service Tax Reg.No. AABCR6747BST001
The policy wording with detailed terms, conditions and exclusions are available on our website www.reliancegeneral.co.in
Consolidated stamp duty paid vide Receipt No. MH
00081948420
1415E
dated 23/05/2014
** Not Applicable for the State of Jammu & Kashmir.
For claims please contact us on 30338282 or email us at claims.rgi@relianceada.com or visit our website www.reliancegeneral.co.inz
Note: In the event of dishonor of cheque, this policy document automatically stands cancelled from inception irrespective of whether a separate communication is sent or not.
“It is hereby declared and agreed that all pre-existing damages to the vehicle having occurred prior to the commencement of cover are excluded from the scope of the policy.
Date of issue: 10/10/2014
For Reliance General Insurance Co. Ltd.
Duly Constituted Attorney(s)
Registered Office: 19,Reliance Centre, Walchand Hirachand Marg, Ballard Estate, Mumbai – 400 038, India
Registration No.
Place of
Registration
Engine No
Chassis No.
Make/Model &
Variant
Type of Body Cubic Capacity Year of
Manufacture
Seating Capacity
of side car (if any
including driver)
Net Premium
Rs.
IDV (Insured's
Declared Value)
Rs
MH06AC4225 76563 TATA Trailer 2000 2006 3 0.00 900,000.00
PEN 11065 4018 AL
Intermediary Name & Code
Intermediary Contact No:
11A18382 / AMARPREET KAUR SAINI
9321707654
Registered Office: Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate ,Mumbai - 400 001
General Insurance