23: SCHEDULE CUM CERTIFICATE ACT ONLY

00 INSURANCE POLICY- PRIVATE CAR

InsureMo
Liability Only Policy / Certificate No : POPMCAR00101925523

QR code for mobile download app: Alternate Policy No :

Policy Issue Date : 22/08/2025

Please scan the code to view policy details
Customer ID :
Name : Mrs AMBIKA PANDEY Policy Servicing Branch : Mumbai
Address : , Intermediary Name : PolicyBazaar Insurance Brokers Pvt Ltd
,Marigaon Marigaon,
Assam Intermediary Code : 0065359
786007
Intermediary Contact No : null

Contact No : 7002895125 Period of Insurance TP : From:22/08/2025 00:00:00

To:21/08/2026 23:59:59
Email Id : [email protected]
Period of Insurance PA to
Owner Driver

AMBI

Dear Mrs.AMBIKA PANDEY,

Welcome to the SBI General Family. With SBI Act Only Insurance Policy - Private Car, you can be in control & enjoy the journey no matter what
roadblocks life throws at you.

ABOUT YOUR POLICY

Policy/ Policy Issue Period of

certificate no Date Insurance TP

POPMCAR00101925523 From:22/08/2025 00:00:00

22/08/2025 To:21/08/2026 23:59:59

Period of Insurance Policy

PA Cover to Owner Driver Type Geographical Area

Liability Only India

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 | Visit: www.sbigeneral.in
 358.92
0.0 0.0
0.0 0.0 0.0

ABOUT YOUR VEHICLE

Vehicle Make Registration Manufacturing Cubic Capacity /

Model & Variant Number Year Kilo Watt

Maruti Suzuki,Alto & 800 - Lxi 796

AS 21 F 8634 2017

Engine & Chassis Seating RTO

Fuel Number Capacity Location

F8DN5914407 &
Petrol MA3EUA61SOOB56979 5 Marigaon

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 2094.00
Third party property damage -100.00
TOTAL TP PREMIUM 1994.00
TOTAL PREMIUM 1994.00
GST 358.92
FINAL PREMIUM 2353.00
Subject to I.M.T Endorsement Nos.(IMT Nos):
IMT_5
IMT - 20

ADD ON DETAILS Sum Insured Opted (Yes/No)

Consolidated Stamp Duty ₹ 0.5 paid towards Insurance Policy Stamps vide Order No.PB135246678 Dated: 22/08/2025 00:00:00 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 | 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
POPMCAR00101925523 to Download SBI General Mobile App
1800-102-1111 www.sbigeneral.in
561612 on Playstore or Appstore

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | 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 (24*7)

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

3 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

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

For Insurance Ombudsman Offices, kindly visit our website

https://www.sbigeneral.in/portal/buy-online/quick-assist/Locate us/Ombudsman Office List

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: www.sbigeneral.in
 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
to the insured or held in trust or in the custody or control of the insured up to the limits
OF LIABILITY
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 | Visit: www.sbigeneral.in
 IMPORTANT DETAILS

PREVIOUS POLICY DETAILS

Comprehensive
Previous Insurer Previous Policy Number Period of Insurance Previous Policy Type

Cholamandalam MS General
PPN6273627637 02/01/2024 to 01/01/2025 Comprehensive
Insurance Co. Ltd

Financier Details CPA Nominee Details POSP Details

: NA
POSP Name
: NA
POSP PAN Number
, NA
Location
: NA
POSP Code
: NA

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.

Liability Only

InsureMo
02/01/2024
01/01/2025
Comprehensive
InsureMo

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

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

Policy Number POPMCAR00101925523

Policy Holder Name Mrs AMBIKA PANDEY

Intermediary Name PolicyBazaar Insurance Brokers Pvt Ltd

Receipt Number PB135246678

Product Name Act Only Insurance Policy - Private Car

Receipt Date 22/08/2025

Policy Start Date 22/08/2025

Policy End Date 21/08/2026

Premium Paid by Mrs AMBIKA PANDEY

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

Digitally signed by DS
SBI GENERAL
INSURANCE
COMPANY LTD
Date: 2025.08.22

Authorized Signatory
For SBI General Insurance Company Limited

To Verify your Policy details click/visit https://www.sbigeneral.in/policyprint/motor

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.
Liability Only

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: www.sbigeneral.in
 Liability Only
5

PROPOSAL DETAILS

Proposal Transcript For Act Only Insurance Policy - Private Car

Proposer Name Mrs AMBIKA PANDEY
,
,Marigaon Marigaon,
Proposer Address
Assam
786007
Proposer Contact Number 7002895125
Proposer Email Address [email protected]
Policy POPMCAR00101925523 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.

Insured Name Mrs. AMBIKA PANDEY

Nominee details
Name of the Nominee*
% Share of Claim Amount
Date of Birth*
Age*
Gender (M/F/O)
Relationship with Policyholder*
Mobile No. of the Nominee*
Address of the Nominee
Nominee Email ID
Account Number
IFSC Code
Bank Name
Branch Name

* If Nominee is a minor, give the details of Appointee

Insured Name Mrs. AMBIKA PANDEY
Name of Appointee*
DOB*
Gender
Relationship with Nominee*
Address of the Appointee
Appointee Mobile no*
Account Number
IFSC Code
Bank Name
Branch Name

Details as shared by you with us is as below.

YOUR VEHICLE DETAILS

Registration Number AS 21 F 8634

RTO Location Marigaon
Engine Number F8DN5914407
Chassis Number MA3EUA61SOOB56979
First Purchase / Registration Date 30/10/2017
Year of Manufacture 2017
Vehicle Make Maruti Suzuki

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: www.sbigeneral.in
 Vehicle Model Alto
Vehicle Variant 800 - Lxi
Cubic Capacity / Kilo Watt / Gross Vehicle Weight / Horsepower 796
Fuel Petrol
Seating Capacity including Driver 5
Carrying Capacity excluding Driver 4

EXPIRING POLICY DETAILS

Details OD Policy Details TP Policy Details

Insurer Name NA Cholamandalam MS General Insurance Co. Ltd
Policy Number NA PPN6273627637
Policy Start Date NA 02/01/2024
Policy End Date NA 01/01/2025
Policy Type NA NA
No Claim Bonus % NA NA
Claim Made No No

COVERAGE & TERMS PROPOSED

From:NA
Period of Insurance Own Damage
To:NA
From:22/08/2025 00:00:00
Period of Insurance Third Party
To:21/08/2026 23:59:59
Period of Insurance PA cover to Owner Driver

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: www.sbigeneral.in
 0.0 0.0
0.0 0.0
0.0
0.00.0
0.0
0.0
0.0
0 0.0 0.0
0.0
POPMCAR0010
0.0 0.0
ADDITIONAL COVERS

PA Cover to Owner Driver of Rs. 15 Lakhs No

PA Cover to Unnamed Passenger / Pillion Rider No
0.0
PA cover to Paid Driver No
Legal Liability to Paid Driver / Employees No 0,0
Third Party Property Damage Restriction Limit 6000
Add on covers - Kindly refer Policy Schedule
Hypothecation / Lease / Hire Purchaser Name
Policy premium including Tax 2353.00
2353
Valid PUC certificate will be carried in vehicle Yes
0
PA Cover to owner Driver has been opted out by you in the Policy based on your declaration that you are holding an alternate insurance policy.
You will share the copy of same if required by the Company.
0
I/We agree to receive policy document on registered mobile number / email address as given in this document.
6 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.

0 0
0
6000

InsureMo

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 | 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
Compulsory Deductible applicable under this policy is - Rs
10 Special Conditions and Not applicable
Warranties (if any)
12
13 Policy
Grievance
Servicing
Redressal
- and 1.Claim
Details of
intimation
protection& reaching
of policyholder’s
to our designated
interest-The
officials
Company contact 9. Grievance Redressal
pleasehas
Claim
Policyholders
Intimation
Protection
and Processing us
adopted
at Grievance Redressal Policy, wherein the Grievance Redressal Process
Email:
Procedure,
[email protected]
details of GRO, Ombudsman details and link to Bima Bharosa
Toll-Free
Portal is mentioned
number 18001021111
below.
Website: www.sbigeneral.in Whatsapp: 7669800345
Stage 1app
Mobile SMS: 561612
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/0449cac1bcd144bbb160d3f6b71
4fbbd.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 hereon 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

SBI General Insurance Company Limited | Act Only Insurance Policy - Private Car | Call (Toll Free) :1800 22 1111 , 1800 102 1111 | Visit: www.sbigeneral.in
 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.
3. Previous policy details (ie. Disclosure of NCB, previous claim
details)
Declaration by the Policyholder:

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 | Visit: www.sbigeneral.in