SCHEDULE CUM CERTIFICATE ACT ONLY

INSURANCE POLICY- PRIVATE CAR

Policy / Certificate No : 0000000124435535

Alternate Policy No :
QR code for mobile download app: Policy Issue Date : 07/05/2025

Customer ID : 0000000074195366

Policy Servicing Branch : New Delhi Pitampura

Name : Mr.ALGU .
Intermediary Name : Girnar Insurance Brokers P Ltd
Address : VILL-MOBARAKPUR MOBARAKPUR,NA
Chandauli Chandauli,
Uttar Pradesh Intermediary Code : 45786
232103
Intermediary Contact No : +91-7551196989
Contact No : +91-9670404945 Period of Insurance TP : From:10/05/2025 00:00
To:10/05/2026 Midnight
Email Id : [email protected]
Period of Insurance PA : From:10/05/2025 00:00
to Owner Driver To:10/05/2026 Midnight

Li 000000012443

Dear Mr.ALGU .,
Motor to- Private 00:00
Motor - Private 10/05/2026
Welcome the SBI GeneralMJC4L65908
Family. With SBI
0000000124435 MA1TA2MJNC2
Act Only
ALGUInsurance Policy - Private Car, you can be in control & enjoy the journey no matter what
.
000 roadblocks
PMCAR02
UP 16 AMlife throws at you.
7239 10/05/2025
ALGU .

ABOUT YOUR POLICY

Policy/ Policy Issue Period of

certificate no Date Insurance TP

0000000124435535 From:10/05/2025 00:00

07/05/2025 To:10/05/2026 Midnight

Period of Insurance Policy

PA Cover to Owner Driver Type Geographical Area

From:10/05/2025 00:00 Liabillity Only India

To:10/05/2026 Midnight

SBI General Insurance and SBI are separate legal entities and SBI is working as Corporate Agent of the company for sourcing of insurance products.
SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free):1800 22 1111,1800 102 1111|
CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in
 0000000124435

ABOUT YOUR VEHICLE

Vehicle Make Registration Manufacturing Cubic Capacity /

Model & Variant Number Year Kilo Watt
Mahindra &
Mahindra,Scorpio,Lx 2.6 UP 16 AM 7239 2012 2609
Turbo -7 Str

Engine & Chassis Seating RTO

Fuel Number Capacity Location

Noida / Gautam Buddha

Diesel 7 Nagar
MJC4L65908 &
MA1TA2MJNC2M60628

COVERAGE DETAILS
Your Policy provides protection such as :
Protection towards Third Party Liability

Death or Injury to any Third Party

Personal Accident to Owner Driver (if opted)

Damage to Third Party Property

WE COVER YOU FOR

Third Party Premium
Third Party Baisc Premium 7897.00
7897
Legal Liability to Driver 325 50 9761 750.0 50.00
PA to Owner Driver 325.00
TOTAL TP PREMIUM 8272.00
TOTAL PREMIUM 8272.00
GST 1488.96
FINAL PREMIUM 9761.00

ADD ON DETAILS Sum Insured Opted(Yes/No)

Legal Liability to Driver Yes

Legal Liability to Employees Yes

PA Cover to Un-named Passengers Yes

1488.96 8272 0 0 0 0
PA Cover 0
to Paid Driver 0 Yes

Consolidated Stamp Duty ₹ 0.50 paid towards Insurance Policy Stamps vide Order No.LOA/ENF-2/CSD/03/2025/(Validity Period
Dt.15/01/2025 to Dt.14/01/2027)/47 Date:- 03/01/2025 Dated:2025-05-07 11:27:12.141 of General Stamp Office, Mumbai

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111
|CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in
 WHAT YOUR POLICY DOES NOT COVER

Driving under influence of Accident outside India

intoxicating Liquor/Drugs unless opted for

Driving outside purview of

Liability arising out of Limitation of use or Vehicle
Contractual Liability driven for purpose not allowed

HOW TO FILE YOUR CLAIMS WITHOUT ANY STRESS

In the event of loss and / or damage arising out of the use of the insured vehicle giving rise to a probable claim being led by a Third Party towards
bodily injury / death / property damage, please inform the Company at 1800221111 or SMS ‘CLAIM’ to 561612 or email your details on
[email protected]

RENEWAL

This Policy may be renewed by mutual consent every year and in such event, the renewal premium shall be paid to Insurer on or before the date
of expiry of the Policy or of the subsequent renewal thereof. However, Insurer shall not be bound to give notice that such renewal premium is
due.

Toll Free Number Website SMS RENEW Mobile App

Download SBI General Mobile
1800-102-1111 www.sbigeneral.in 0000000124435535 to 561612
App on Playstore or Appstore

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111
|CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in
 GRIEVANCE REDRESSAL PROCEDURE

If you are dissatisfied with the resolution provided, you may write to
[email protected] We will look into the matter and decide the same
1 expeditiously within 14 days from the date of receipt of your complaint.
For Senior Citizens: Senior Citizens can reach us at [email protected]; Toll
Free - 1800 22 1111 / 1800 102 1111 Monday to Saturday (8 am - 8 pm)

In case, you are not satisfied with the decision/resolution communicated by the above office, or
have not received any response within 14 days, you may send your Appeal addressed to the
Chairman of the Grievance Redressal Committee at : [email protected]. or contact at: 022-
42412070
2 Address: Grievance Redressal Officer, 9th Floor, A & B Wing, Fulcrum Building, Sahar Road,
Andheri (East), Mumbai 400 099
List of Grievance Redressal Officers at Branch:
https://content.sbigeneral.in/uploads/0449cac1bcd144bbb160d3f6b714fbbd.pdf/

In case, you are not satisfied with the decision/resolution communicated by the above office, or
have not received any response within 14 days, you may Register your complaint with IRDAI on
3 the below given link https://bimabharosa.irdai.gov.in/Home/Home

If your grievance remains unresolved from the date of filing your first complaint or is partially
resolved, you may approach the Insurance Ombudsman falling in your jurisdiction for
Redressal of your Grievance. The details of the Insurance Ombudsman can be accessed at
4 https://www.cioins.co.in/Ombudsman

If Your issue remains unresolved You may approach IRDAI by calling on the Toll-Free no.
155255 or You can register an online complaint on the website http://igms.irda.gov.in

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111
|CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in
 For Insurance Ombudsman Offices, kindly visit our website
https://www.sbigeneral.in/portal/buy-online/quick-assist/Locate us/Ombudsman Office List

TERMS AND CONDITIONS

LIMITATION As per Motor Vehicle Rules, 1989 - 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)
AS TO USE Pace Making, e) Speed Testing, f) Reliability Trials, g) Any purpose in connection with Motor Trade.

Our
Simply do not use vehicle for the purpose it is not allowed.
Recommendation
Any Person including the Insured provided that a person driving holds an effective driving license at the
DRIVERS time of the accident and is not disqualified from holding or obtaining such a license; provided also that
CLAUSE 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 Vehicle Rules, 1989.

Our
Drive only when you hold a Valid Drivers License in India.
Recommendation
a. Under Section II-1 (I) of the Policy-Death of or bodily injury to any person so far as it is
necessary to meet the requirements of the Motor Vehicle Act, 1988.
LIMITS b. Under Section II (1) (ii) of the Policy-Damage to property other than property belonging
OF LIABILITY to the insured or held in trust or in the custody or control of the insured up to the limits
specified Up to ₹ 7,500,00/-.
c. PA Cover for Owner-Driver under Section-III CSI - ₹1,500,000 /- (if opted).

Our
Know what your policy covers.
Recommendation

Warranted all damages existing prior to inception of risk are excluded from the scope
of Policy.
SPECIAL
CONDITIONS The Policy has been issued subject to valid Pollution Under Control (PUC) Certificate disclosed by you as
an insured on or before the date of commencement of the Policy. If the PUC Certificate is not found valid
at any point of time during the policy period, the Company reserves the right to cancel the policy.

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111
|CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in
 IMPORTANT DETAILS

PREVIOUS POLICY DETAILS

Previous Insurer Previous Policy Number Period of Insurance Previous Policy Type

From 10/05/2025 00:00 to

144 POPMCAR00100754632 2
10/05/2026 Mindnight

Financier Details Nominee Details POSP Details

Name : Girnar Insurance Brokers P Ltd

Code : 45786
, ,,
Contact Details : +91-7551196989

Landline Nos :

DECLARATION
As part of our Go Green initiative, your policy will be issued digitally to your registered mobile number via WhatsApp, SMS, and email. By
issuing an e-policy, we help conserve the environment by saving a tree. An electronic policy document holds the same legal validity as a
physical copy.

However, if you would prefer to receive a physical copy of your policy document, simply send an SMS with the message "PRINT <Policy
Number>" to 561612 from your registered mobile number.

PREMIUM RECEIPT

This is to confirm and certify that we have received premium(s) from the below named Policy Holder

Policy Number 0000000124435535

Policy Holder Name Mr. ALGU .

Intermediary Name Girnar Insurance Brokers P Ltd

Receipt Number 000062457154

Product Name Act Only Insurance Policy - Private Car

Receipt Date 07/05/2025

Policy Start Date 10/05/2025

Policy End Date 10/05/2026

Premium Paid by ALGU .

*Cheque dishonor - If premium paid through cheque, the policy is void ab-initio in case of dishonor of cheque.

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111
|CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in
 Authorized Signatory
For SBI General Insurance Company Limited

GST INVOICE : You may download GST invoice from www sbigeneral.in\download\

The information provided herein above is for the purpose of illustration only. For more details on risk factors, terms, conditions and exclusions,
please read the Policy wordings (www.sbigeneral.in/portal/act only insurance policy-private car/policy wording) carefully.

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111
|CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in
 PROPOSAL DETAILS

Proposal Transcript For Act Only Insurance Policy - Private Car

Proposer Name ALGU .
VILL-MOBARAKPUR MOBARAKPUR,NA
Chandauli Chandauli,
Proposer Address
Uttar Pradesh
232103
Proposer Contact Number +91-9670404945
Proposer Email Address [email protected]
Policy 0000000124435535 is issued based on the correct information given by you. In case any information is incorrect or require changes we
request you to revert within a period of 15 days from receipt of this document failing which it will be deemed that you are agreeing to
correctness of the information mentioned in this document.

Details as shared by you with us is as below.

YOUR VEHICLE DETAILS

Registration Number UP 16 AM 7239

RTO Location Noida / Gautam Buddha Nagar
Engine Number MJC4L65908
Chassis Number MA1TA2MJNC2M60628
First Purchase / Registration Date 20/2-/08-0
Year of Manufacture 2012
Vehicle Make Mahindra &amp; Mahindra
Vehicle Model Scorpio
Vehicle Variant Lx 2.6 Turbo -7 Str
Cubic Capacity / Kilo Watt / Gross Vehicle Weight / Horsepower 2609
Fuel Diesel
Seating Capacity including Driver 7
Carrying Capacity excluding Driver 6

EXPIRING POLICY DETAILS

Details OD Policy Details TP Policy Details

Insurer Name NA 144
Policy Number NA POPMCAR00100754632
Policy Start Date NA 11/05/2024
Policy End Date NA 10/05/2025
Policy Type NA NA
No Claim Bonus % NA NA
Claim Made No No
7

COVERAGE & TERMS OPTED

From: NA
Period of Insurance Own Damage
To: NA
From:10/05/2025 00:00
Period of Insurance Third Party
To:10/05/2026 Midnight
From:10/05/2025 00:00
Period of Insurance PA cover to Owner Driver
To:10/05/2026 Midnight

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111
|CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in
 50 0
0 900004544 700000946
700000941
000000012443 700000947
0
700000940 325

ADDITIONAL COVERS

PA Cover to Owner Driver of Rs. 15 Lakhs Yes

PA Cover to Unnamed Passenger / Pillion Rider No
PA cover to Paid Driver No
Legal Liability to Paid Driver / Employees Yes 1,
Third Party Property Damage Restriction Limit Upto Rs.750000
Add on covers - Kindly refer Policy Schedule
Hypothecation / Lease / Hire Purchaser Name ,
Policy premium including Tax 9761.00

Valid PUC certificate will be carried in vehicle Yes

I/We agree to receive policy document on registered mobile number / email address as given in this document.

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 IN BREACH OF COMPLYING WITH THE PROVISIONS OF THIS
SECTION SHALL BE PUNISHABLE WITH FINE WHICH MAY EXTEND TO RUPEES TEN LAKH.

I/We confirm that premium is paid from bonafide sources of income.

Disclaimer : Corporate & Registered Office: Fulcrum Building, 9th Floor, A & B Wing, Sahar Road, Andheri (East), Mumbai - 400099. | For SBI General
Insurance Company Limited IRDAI Reg. No. 144 dated 15/12/2009 | CIN: U66000MH2009PLC190546 | UIN : IRDAN144RP0001V01200910 | SBI Logo
displayed belongs to State Bank of India and used by SBI General Insurance Co. Ltd. under license.

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111
|CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in
 CUSTOMER INFORMATION SHEET
This document provides only key information about your policy. Please refer to the policy document for detail terms and conditions.
Description
SI NO Title Policy Clause Number
(Please refer to applicable Policy Clause Number in next column)
1 Name of Insurance Product Motor Act Only- Private Car
2 Unique Identification Number IRDAN144RP0002V02201819
allotted by IRDAI
3 Structure Limit of liability -Indemnity 2.Coverage, section 2a ,2b
4 Interests Insured Interest insured is Third Party liability arising out of insured vehicle 2. Coverage, section 2a
5 Sum Insured / Motor Insured Policy covers the following : 2..Coverage ,section 2a
Declared Value 1. coverage to the Third Party liabilities
2. Third Party Property Damages upto INR 750,000 with an option
to restrict the coverage to INR 6000 whereby there will be
reduction in Liability only premium
6 Policy Coverage (What the This policy covers
policy covers?)
1. Third party liability in case of injury/death of the person, or any 2. Coverage section 2a, 2b
damage caused to the property of the third party
2. If Compulsory Personal Accident cover is opted by you, the
policy covers Personal accident up to Rs 15 lakh for
individual owners while driving.
For complete details on the coverage, limits, exclusions, terms &
conditions, refer policy wording on www.sbigeneral.in
7 Add on Cover Not applicable
8 Loss participation Not applicable
9 Exclusions The Insurer shall not be liable with respect to 6.General Exceptions
(what the policy does not cover) • Driving without a valid licence

• Driving under the influence of drugs and alcohol

• Own damage cover to vehicle

• Unauthorized usage

• Driving outside geographical area

For complete details on the exclusions, refer policy wording.
10 Special Conditions and Not applicable
Warranties (if any)
11 Admissibility of Claim Admissibility: Admissibility of claim can be done by filing the FIR with the 7. Conditions
police immediately after the accident and file a compensation claim case
in the Motor Accident Claims Tribunal. The claim would not be
acceptable if it falls under General exclusion/condition mentioned in the
Policy Wordings.

Policy can be cancelled on the ground of mis- representation, mis -

declaration, fraud, non-disclosure of material facts.
32 12 Policy Servicing - 1.Claim intimation & reaching to our designated officials please contact
Claim Intimation and Processing us at
Email: [email protected]
Toll-Free number 18001021111
Website: www.sbigeneral.in Whatsapp: 7669800345
Mobile app SMS: 561612

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111
|CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in
 13 Grievance Redressal and Details of protection of policyholder’s interest-The Company has 9. Grievance Redressal
Policyholders Protection adopted Grievance Redressal Policy, wherein the Grievance Redressal Process
Procedure, details of GRO, Ombudsman details and link to Bima Bharosa
Portal is mentioned below.

Stage 1
To raise the query, you may write to [email protected]
Toll Free - 1800 102 1111 Customer Care Toll-free number is available
24/7

Stage 2
If you are not satisfied with the decision communicated by the above
office, or have not received any response within 14 days, send your
appeal at : [email protected]. or contact at: 022-42412070
Address: Grievance Redressal Officer, 9th Floor, A & B Wing, Fulcrum
Building, Sahar Road, Andheri (East), Mumbai 400 099

List of Grievance Redressal Officers at Branch:

https://content.sbigeneral.in/uploads/0449cac1bcd144bbb160d3f6b7
14fbbd.pdf/

Stage 3
In case, you are not satisfied with the decision/resolution
communicated by the above office, or have not received any response
within 14 days, you may Register your complaint with IRDAI on the below
given link https://bimabharosa.irdai.gov.in/Home/Home

Stage 4
If your grievance remains unresolved from the date of filing your first
complaint or is partially resolved, you may approach the Insurance
Ombudsman falling in your jurisdiction for Redressal of your Grievance.
The details of the Insurance Ombudsman can be accessed at
https://www.cioins.co.in/Ombudsman.

If Your issue remains unresolved You may approach IRDAI by calling on

the Toll-Free no. 155255
List of Ombudsman offices with contact details are attached as an
Annexure-1. For updated status, please refer to website
www.irdaindia.gov.in

14 Obligations of prospective The Policy shall be void and all premium paid here on shall be forfeited to
Policyholder / Customer the Insurer, in the event of misrepresentation, misdescription or non
disclosure of any material fact by the policyholder pertaining to the
proposal form, written declarations or any other communication
exchanged for the sake of obtaining the insurance policy by the Insured.

Disclosure of other material information during the policy period:

1. Change in insured name
2. Change in the vehicle details i.e make, model, cc, extra fitments,
engine & chassis no, class of vehicle. In fact all (In fact, all relevant
details are in the RC book/card and a copy of same may be
handed over) Tax paid details; Certificate of fitness, license
validity etc.
Declaration by the Policy Holder:

I have read the above and confirm having noted the details
Place:
Date: Signature of the Policyholder
Note: For product related documents including Customer Information Sheet, kindly refer to the below link: https://www.sbigeneral.in/downloads
In case of any conflict, the terms and conditions mentioned in the policy document shall prevail

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111
|CIN:U66000MH2009PLC190546|Visit:www.sbigeneral.in