You are on page 1of 4
AutoSecure re eee eeler Packag} ‘Appleston Na: ote {Pee worse vi eens. Pe at ol ten cp nek near ie eo dco cs art For vehi we or Set Domest, Pst an Professions Purpose oy eter Hi a Reward) Packie —-Patage Fre Het) Pacape re ony) Paka Tat On | _Infrmation fr feds marked in bod on grey background wih asterisks mandatory [FRORSHEPEDEIIEE) (rose cove spsce between the nome) Med, T i T ce CEE Spee eorsse aes 3. Educationsl Qualcation: es ele a yee a ae es os lang Tear nyo ortho Rago Grins at Chi ar Ta Crass any ran Nee se Inanenoue Isr Patol Dat ‘owcare nme ‘eve rata hie Tae oto FERRERO MOON tate) tant Sue tobrscy/Tonmfonte |) Ont Rand One renewed Ooled Vals JO oft vese wl be demos tbe he Sum rector he purpose be | Notexcasdng 6ronts * Paty ond tbe tea tine commencement teach peer pea tr ach rere eige Ye Vo ee hte tobe ied ont ba of rants neg sting pce tbat and eel are ve | "cpsing § monte bu oa Prpored fr imrenes tte hn of commencement narne rr on eda angreon at be ches pechie Tho ce otal oder seetaree toy fanstohwvehiewareee” | sceedng ten bt Fustdintwomeniachrersiaed epics tinevenckreaso Manaetobefirea These ot | etekeoNg 2 Yes om szewoe secon ston apteaeto he pore of Yor oetCanuiv eal ons TLC Eeantng yer bt tina com Avent ibe corsderediomre Comers sggegeecon treet ander por ftw | tovercevrg 3 ows a re suet andconson oh pole nest Te ots Freaating yor bt [BV othe brenda lage dol cacee mod ha veils mod wich he tinea yet om ruatocirs ve Saco to marti tobe Soarmnadon te bromot wn ancrsunding betwen | Exentin yest etn on cued ocncatarg Syn Ea ‘Sie Cu Value peal for To Whar ony T No Eccl Acessories Other hn factory te ets Azceores (Ohara tony fe) Mate Mode ovite) i NGF et provide by manutetures) i For Private Car Package Policy -UIN not allotted by IRDAUFor Two Wheeler Package Policy - UIN No.TAG-MO-P14-04.V02-14-15 'ste revous insurance you na? Yes to Type at Cove: et Paley Prete rong Ply / Cover Not No. Exiy Dates NeBin your essing pofey * Aso ‘Ws any sim reported during the expiring policy period? mL] tim mene hc ee] oar 7 2 zi 4 5 ‘you anit or NCB on enon? eer NCB Decoration! Yeu || mo * Decined your Proposal Oo equa an ness i Prema oodng o Concer Rete Renew srsoted Speci Constions or sco 114. Man vr Bae: ‘a CrinaBwtenes® Years | |_| ‘oy Ober oe Yoo ent: Nae [ | Forte ows ever mtr rom detecve sion or hang or any pal ir Yeh rpecaton tie Pca toate onrtLoon Appleton No For Private Car Package Policy ~ UN not allotted by IRDA/For Two Wheeler Package Policy - UIN No.TAG-MO-P14-04.V02-14-15 ‘UntlamadPerton Peto! Acct Coe! or eating capac, dng iver (Mas, R20, 00 ach a Mp os. 10.900) sins. | Wider ep! Laity Paid Dover esol Acun Covt or Owner Diver compu are Nomina 6 Ae ame Appoint Neminw Mir 4 Comparer Pa cover evn ive connote anid ere rohice teweed bys compeny primase mort sar body cere ‘ste he cra rer doesnot hol neers vers teak ‘Do yauwieh totus PersanalAcoencovrtornames poron # ES, ga name nd Capt! Sam nawo Copter Nar ‘rps oman” aaa ene a » 2 2% Not: The mannan CS aval per esa ie a? Lace oe of Piva Cran a1 Lsin th at of Motrin Two Wheaten) aoa 0 Enploveeswaveing/eang he vie (ar han ped dvr Nos Urn) Saldrsatremanarploed a vermin apa pial for Prat Caren) seo occnsrenby Burpy, Hour beatin end Te. opto Two Wels ni Memon No. ‘iy Date ‘Tha PayPopanyOarisae Cover eit tR6000 ony \otmry Deduct chosen ver and ebove Conputerydedvetbe In eas of Pivat Opto avis re in mle ot 0) Fi TON Re2000- Re EON-o Re SOOG.—ReSOOO- oR 700 [Re EEO oR ON Innes fT Whose, Optons vaste ae ‘esos Specialy dexgned or as of Bina nSszppadMnty Challenged Peon ad ndcae in Rein Carte, (tan IC e26y) ail weed wae own praia (Ola ood or gerard ute by RTO Venice td th Ani Tao deca approved by ARAL [ach nts cerfestanuedby ay utomebie ezoiten) \Vonioeisttos win a Fire Giese Fu Tak, Voice wi bo use or Dvn Tons. | Ynage Ca atid by Vintage an Classe Car Co a ‘mpate ahil without paymart of etme ty Extension a Courtas GonlateshNepaShleyPabisten Neder Larka) Veni ven by nrecomandonl ice of power, Dati Pow Poa Ps 9 Patina Sappie ‘Seppe Pas = Dapeisin, — Depresiaion + Dagcsiss —) = Dapreson —] = Dapretoson = bape Falmbrerant ” Remburseart Femouswomeet "Rarmburamant” Rammturenant—_* Rerusesnant +E Socre + DaiyAlowncs sBuivAlonmncesSxrmmaie” «Gown + Consumatie apenas sRaumIDlWvoKe «Tyesecue «Tye secure "fan Rolocevant * "fat Replacement eal ne " pesitance wet aes epi Gis Fir, Pate ater Paris consumable Egon nea Perna orange "10000 4. $0000 |) Any oer ngs Secre EmugoreyTnapor Hotel penser Me 10000 50009 Any ober Wiis cacue Pl vec Key Replace | 25000 Re 000 " ne Dacron Ronit aly Alonance Toe Secure atta iwi ot apple er aed ca) ond Se Aositance Deprcaton Se | Ful Replacement Seis (aR on covers He ite) DeprecaonAlonance etuolnvlee Censure Expense Emagen medical expenses On muti Ri 6.000! Rs Irn Re. 00-8 simu Rs, 1.0500: ‘cin i PaxyPopety Damage Covet multiteotNR E0000) (rina, SODI0- 8 maximus 15.0200) ‘Ana Pesoal Accent Corer Own Divan mp of 50,09) Aa mim Re. 120,090 manu Re. 160.000!) ‘Aina Pesoal Aedent Core Urn Psonsn muti Ri, 50.2004) Re IMumberctprsons__—_) Irina Re. 00,00 ram 100.000) Source offnds name / where soni: Salary | Baines Cnr ase Sosy. Premium pl by sth / Cheque No meso Insure’ PAN cord Number Inne sercectPaN Ce, seg densa ete aera poe ca SS no ne ee oe eer eee tthe elence Ine nPrevenion of Money Laundering Act 202 T's et he Company has he io cal for Gourmet esta sorces fs Th ‘are cma sated rayann atin nor have fn at yn corp out io nay he as, eso 1 Rao: sono on ne, plas sty th Coumry ‘2 peor gation Corortins Goverment Non Government Orgone Socay Tat Parneahio Iernationsl Orpen Cooperatives ‘Sectan 25 Company “Rie eat nar wh TG Garr inarans carany Uke neg of he ee eb nthe roomy an cfm eae rer ta ley woul stand fotcted (We apr hat Eva appcation and desaraton shal he promasory a aha be te bans of he cont etre Matas hd ‘ia At General insrance Company Linea {We cnt te have eed on ances the covmapn, es sé condense anes eae he mga paey af race dng ih te al contra peerond oy the Comsat e ag secre aundeae ha! ay austin saat re fret by mtu nt prepes fm othr any range nw nomon se ened y mae ae he cabmion propor om hen te sane ‘Sl fr ola sore te Crary ny ‘ute yh rocearaguinirs ert ret ‘Sdphonsconvrsten We tre tate urncewasidbeafectoe Ey onarcepianes of he saplacon by he Crary one erate ech Piaalamiyaneksirsivance tne vet of eonroaonan of cheque ey conser kamen af promlenby Company ih ey abe eked Een ot’ one te Company sat nt Se enpanale er ybbie sfwrsevet rte ender hs Poy Teast ree conta of masa an yEnc sts ey amen a ecco Oe compan aba No Clam Bona" (NCB canton ror subi but NCB cle) (Sate of what vr ro apa {eset a ate of NCS elnmed by rans comet an at NO CLAM hos sen nthe enna Peey Pad Copy Ply ancowed {efarer undertake federations ound increta benefieunder tne Ply apart! Satna te Py wl an fares For Private Car Package Policy - UN not allotted by IRDAUFor Two Wheeler Package Policy - UIN No.TAG-MO-P14-04.V02-14-15 ‘abe the Ragtory egarert se an efit payment feud / cain ny haugh Ehncvrs Clog Systm ESI Natoal Beever ands Tantr NEFT ‘ea ime Goes Sertomer TSI tar Moble Pyar Sere DAS), or ha Purpose ave sub he ohowng Gnas te aued svat occu ame te Bak Beane Typ of Account 8 Acssunt et ctu ers (te spec) 1 pan ch ot loth above mane aecoutthen cael hag of she ord acm tobe aah “Seaton 4 of rane At B36 Pehibion fabs 1. Noparzon shat stow aero alow ster det ornare arn nauremart tan prson he Ot ot ene or cornu anneuranesin respect of ny tin fit retina toes or properyn ida ar esto the whl oat of be camssen peasy eb a rerum shown on te Pyro Sol ‘hy peso ang ctr oneningo conning pay acc any abate, nce senate ray lowed h aeaaance wae pobahes poset a 2A porcn rang atin conphing with provisos hi eto. ba for pny hich may extn oan bh ps ecCorparataranch Approval No ectrction Aro ve —______tme: ‘Aoorving Atos Nome, Sanat Dae ame ot pecting haem Sprawe Sanpot hxc Arey For PRODUCERS USE ONLY DOCUMENTS ATTACHED cent sate Exoing Pokey win ScedeCovente Covel Covee any ‘Sse rol RC Cone 28630) counchegoehn No Reserving (Orena aowaten Paymertnanare me Ingato por ReMi) cance covet oy Protiers Sn" Onerian Exc Sion 6 at FATIG AAT PAVATECAR ‘onvonce mv “Tr Fremia A apen) ENGLPG KIEV @ 4% (crt ie ence ire 0) Baie Asoo @4% wna Driver PA 1004) Londng coun tony is vere 504 (elu PAtoFasenge Re pe10000) (Ae Tht Doves Totty Peis @) (0 265 s00. Tot rena 0 CAM Discount ‘ence Tox (A apn () (© % tas 200 (nce “et 00 Fremam Tous anont tae @ nero he jot mat of slotaton. Far mor ln ri ton, ers an condos oss reed males brochure aor concing# ae Tata AIG General Insurance Company Limited "AKI Tol Foe No 1800296 70 Fax: 0226803870 "nal cvstomersuppristatatcom For Private Car Package Policy ~ UN not alloted by IROAUFor Two Wheeler Package Policy - UIN No.TAG-MO-P14-04.V02-14-15

You might also like