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Servicing Office Address

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Dharamshala Branch,267, Civil Lines, Near Kangra Central Co-Op Bank,

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Head Office, Dharamshala, Kangra, Himachal Pradesh, Pin : 176215

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GSTIN No: 02AAACN9967E2ZE

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RECEIPT

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Customer Details Collection Details

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Name : Mr KAMAL KISHORE SHARMA Agent Code : 9000126025

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Address : S/O AH. PRAHLAD KUMAR SHARMA R/O Collection Number : 42120281238000002900

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HPG BANK BRANGAL TEH SALOONI DISTT Collection Date : 26/06/2023

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CHAMBA , HIMACHAL PRADESH , SALOONI Bank Account : 9174

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Pin Code : 176308

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Received with thanks from Sri/Smt Mr KAMAL KISHORE SHARMA

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a sum of 15171 (RUPEES FIFTEEN THOUSAND ONE HUNDRED SEVENTY ONE ONLY) by CD

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towards 1 Year Package Policy Policy as per details given hereunder

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Sl Policy Number TR Code End/Ren/Dec/Clm End/Ren/Dec/Clm A/C Particulars A/C Head Credit Amount Debit Amount Amount
No. Year Number (General Ledger) Received

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1 42120231236160001596 11 C.D CONTROL A/C 5076 0.00 15171.00 -15171.00

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2 42120231236160001596 11 CASH PREMIUM A/C 5083 12857.00 0.00 12857.00
01
3 42120231236160001596 11 CGST_HP_Int_Liab 7334 1157.00 0.00 1157.00
0
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4 42120231236160001596 11 SGST_HP_Int_Liab 7335 1157.00 0.00 1157.00

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TOTAL : 15171.00 15171.00 0.00

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Particulars : CD
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For National Insurance Company Ltd.,

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1.Please quote collection no. and date in all correspondeces

2.The stamp has been defaced and retained at the office against the issued
No

policy.
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3.We hereby declare that though our aggregate turnover in any preceding
financial year from 2017-18 onwards is more than the aggregate turnover
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notified under sub-rule (4) of rule 48, we are not required to prepare an invoice
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Authorised Signatory
in terms of the provisions of the said sub-rule.
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NIC/UBPORTAL/9000126025 26/06/2023 02:55 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
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 Issuing Office Name & Address
DHARAMSHALA BRANCH ,267, CIVIL LINES, NEAR KANGRA CENTRAL
CO-OP BANK, HEAD OFFICE, DHARAMSHALA, KANGRA, HIMACHAL
PRADESH, PIN : 176215
Tel: Fax: 01892 223287 (G)
GSTIN No: 02AAACN9967E2ZE

National Insurance Company Ltd.

Registered & Head Office: 3, MIDDLETON STREET, POST BOX NO. 9229, KOLKATA - 700 071
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
Form 51 of the Central Motor Vehicle Rules, 1989
Policy No: 42120231236160001596 Private Car 1 Year Package from 14:52 Hrs of 26/06/2023 to Midnight of 25/06/2024 IXI
Policy
Insured Details
Name : Mr KAMAL KISHORE SHARMA
Address : S/O AH. PRAHLAD KUMAR SHARMA R/O HPG BANK BRANGAL TEH SALOONI DISTT CHAMBA , HIMACHAL PRADESH , SALOONI
Pincode : 176308 Telephone : 7018420354 Email : [email protected]
PAN No. : xxxxxx573R GSTIN No. : Aadhar No. : xxxx xxxx 7840
Channel : VIKRAM KASHYAP Mobile : 9418039251 Email : [email protected]

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Aadhar : PAN : xxxxxx616J Code. : 421202 / 9000126025

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Break-in Approver : S C MUSAFIR(33548)

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Vehicle Details

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Make & Model Private Car TATA NEXON XZA PLUS S

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Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District

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HP-81-2350 REVTRN11GZXK45381 MAT627225LLH18310 HATCHBACK 1199 2020 1+4 CHAMBA

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Geographical Area : INDIA.

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Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV

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Rs.6,60,000 - - - - Rs.6,60,000

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OD Premium Breakup in Rs. TP Premium Breakup in Rs.

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Basic OD Premium 17,292.00 Basic TP Premium 3,416.00

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(+) Electrical Access. Premium - (+) WC for Driver -

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(+) Bi-fuel kit Loading - (+) Wider Legal Liability to employees so -
(+) Geographical Area Extension - (+) Geographical Area Extension -
(-) Vol. Excess Discount - (+) PA to owner driver YES 295.00
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(-) Auto. Assoc Discount - (+) PA to unnamed PAX ( 5 No. x Rs. 2,00,000 ) YES 500.00
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(-) Anti-theft Discount - (-) Discount For Limited TPPD -

(-) Other Discount - -8,646.00 (+) Bi-fuel kit Loading -
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(-) NCB Discount TP Total (Rounded Off) 4,211.00

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(+) Nil Depreciation - OD Total (Rounded Off) 8,646.00

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(+) Nil Depreciation Plus - TOTAL PREMIUM 12,857.00

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(+) NCB Protect - GST 2,314.00

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(+) Engine Protect - NET PAYABLE 15,171.00

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(+) Invoice Protect - Collection Number :42120281238000002900 dated 26-Jun-2023

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(+) Consumables Protect - Subject to IMT Endorsement No. 16,24,25

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(+) Lock-Key Protect - Prem: SI:

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(+) Loss of Personal Belongings - Prem: SI:

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(+) Loss of Driving Licence -

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OD Total (Rounded Off) 8,646.00

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Excess : Compulsory: Rs.1,000 Imposed: Rs.0 Voluntary: Rs.0

Limitation as to use : 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) Pace
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making (e) Speed Testing and Reliability Trials (f) Use in connection with Motor Trade
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Drivers Clause : Any person including Insured Provided that a person driving holds an effective driving licence at the time of the accident and is not disqualified from holding or obtaining such a
licence. Provided also that the person holding an effective Learner's Licence may also drive the vehicle and such a person satisfies the requirements of Rule 3 of Central Motor
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Vehicles Rules, 1989.

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Limits of Liability Clause: Under section 1(i) Such amount as is necessary to meet the requirements of the motor vehicle act 1988.
Under section 1(ii) Damage to third party property is Upto Rs. 7,50,000 . PA Cover under section 3 for owner-driver is Rs. 15,00,000.
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IMPORTANT NOTICE : The Insured is not indemnified if the vehicle is used or driven otherwise than in accordance with this schedule.Any payment made by the company by reasons of wider terms
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appearing in the certificate in order to comply with the Motor Vehicles Act,1988 is recoverable from the insured .See the clause headed "AVOIDANCE OF CERTAIN TERMS AND
RIGHT OF RECOVERY". For legal interpretation, English version will hold good.
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Financier : SELF OWNED

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Prev Policy : Not Available

Nominee Name : NEELAM SHARMA Relation : WIFE Age : 37 Years
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NOTE : Warranted that in case of dishonour of the premium cheque, this document stands automatically cancelled 'AB-INITIO'.
Policy stamp to be defaced at the respective policy servicing office.
TP Rate Revision Notice: For all policies having an effective date on or after 1st April 2023, the TP premium is subject to revision as may be notified by the IRDAI.
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The Insured should contact and submit the difference of premium to the policy issuing office on issuance of such notification by IRDAI.
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I/We hereby certify that this Certificate cum Schedule of Insurance is issued in accordance with the provisions of chapter X and chapter XI of Motor Vehicles Act,1988.
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Authorised Signatory
For & On behalf of
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National Insurance Company Limited

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NIC/UBPORTAL/9000126025 26/06/2023 02:55 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
Customer Care Toll Free Number: 1800 345 0330 Email: [email protected]