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Servicing Office Address

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Kankarbagh Branch,Commercial House, Main Road, Kankarbagh, Patna,

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Bihar, Pin : 800020

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GSTIN No: 10AAACN9967E3ZG

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RECEIPT

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Customer Details Collection Details

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Name : Mr SUBODH KUMAR Agent Code : 9000156288

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Address : S/O RAN NAGINA DAS,PRIYADARSHI Collection Number : 17050981238000008495

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NAGAR, D P S SCHOOL,BAILEY Collection Date : 24/02/2024
ROAD,DANAPUR, , BIHAR , PATNA Bank Account : 9173

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Pin Code : 801503

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Received with thanks from Sri/Smt Mr SUBODH KUMAR

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a sum of 25714 (RUPEES TWENTY FIVE THOUSAND SEVEN HUNDRED FOURTEEN 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

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No. Year Number (General Ledger) Received

6 00
1 17050931236360004777 11 63 CGST_BR_Int_Liab 7313 1961.00 0.00 1961.00
23
2 17050931236360004777 11 CASH PREMIUM A/C 5083 21792.00 0.00 21792.00
31
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3 17050931236360004777 11 C.D CONTROL A/C 5076 0.00 25714.00 -25714.00

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4 17050931236360004777 11 SGST_BR_Int_Liab 7314 1961.00 0.00 1961.00

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TOTAL : 25714.00 25714.00 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

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2.The stamp has been defaced and retained at the office against the issued
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policy.
3.We hereby declare that though our aggregate turnover in any preceding
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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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in terms of the provisions of the said sub-rule.

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Authorised Signatory
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NIC/UBPORTAL/9000156288 24/02/2024 12:11 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
 Issuing Office Name & Address
KANKARBAGH BRANCH ,
COMMERCIAL HOUSE, MAIN ROAD, KANKARBAGH, PATNA, BIHAR, PIN :
800020
Tel: Fax: 0612-2347752, 2912552
GSTIN No: 10AAACN9967E3ZG
RSA Service Provider: M/s ki MOBILITY SOLUTIONS PRIVATE LIMITED
RSA Service Provider Toll Free Number :- 1800 570 1906
For feedback to RSA:- Email: [email protected]
National Insurance Company Ltd.
Registered & Head Office: PREMISES NO.18-0374, PLOT NO. CBD-81, NEW TOWN, KOLKATA-700156
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
Form 51 of the Central Motor Vehicle Rules, 1989
Policy No: 17050931236360004777 PCV 1 Year Package Policy from 12:00 AM of 27/02/2024 to Midnight of 26/02/2025
Insured Details
Name : Mr SUBODH KUMAR
Address : S/O RAN NAGINA DAS,PRIYADARSHI NAGAR, D P S SCHOOL,BAILEY ROAD,DANAPUR, , BIHAR , PATNA
Pincode : 801503 Telephone : 7004605574 Email : [email protected]
PAN No. : GSTIN No. : Aadhar No. :
Channel : HARISH KUMAR Mobile : 9304198720 Email : [email protected]

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Aadhar : PAN : xxxxxx491B Code. : 79124 / 9000156288

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High. Disc. Approver : MITHILESH KUMAR SINGH(72059)

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Vehicle Details

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Make & Model Tata Motors India Limited TATA ZEST 1.2 XE QJT 75

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

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BR-01-PK-8797 100A20000810315 MAT624004KPN04569 HATCHBACK 1248 2019 1+4 PATNA

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Geographical Area : INDIA.

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Class of Vehicle Passenger Carrying 4-10 Wheeler carrying capacity upto 6

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FastTag ID

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

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Rs.4,50,000 - - - - Rs.4,50,000

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OD Premium Breakup in Rs. TP Premium Breakup in Rs.
Basic OD Premium 15,079.50 Basic TP Premium 7,940.00

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(+) Electrical Access. Premium - (+) Legal Liab.to Driver/Cleaner/Conductor ( 1 No. ) so YES 50.00
(+) Bi-fuel kit Loading - (+) Legal Liability to Passenger ( 4 No. ) YES 3,912.00
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(+) IMT 23 - (+) Geographical Area Extension -

(+) Geographical Area Extension - (+) NFPP Premium -
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(-) Other Discount - -10,254.06 (+) PA for Driver/Cleaner/Conductor -

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(+) Nil Depreciation - (+) PA to owner driver -

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(-) NCB Discount 20% -3,015.90 (+) Hirer Indemnity Premium -

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(+) Towing Charge - (+) Bi-fuel kit Loading -

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(+) Nil Depreciation Plus YES 8,055.00 (-) Discount For Limited TPPD -
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(+) RSA Protect - YES

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OD Total (Rounded Off) 9,890.00 TP Total (Rounded Off) 11,902.00

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OD Total (Rounded Off) 9,890.00

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TOTAL PREMIUM 21,792.00

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GST 3,922.00
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NET PAYABLE 25,714.00

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Collection Number :17050981238000008495 dated 24-Feb-2024

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Subject to IMT Endorsement No. 22,40

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NIC Transcation Id: UBCD2024022421098279 Bank Ref No: ZAX61773372791

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Excess : Compulsory: Rs.500 Imposed: Rs.0 Voluntary: Rs.0

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Limitation as to use : Use only in connection with insured's business.The Policy does not cover use for a) Organised Racing b) Pace Making c) Reliability Trials d) Speed Testing e) Use whilst drawing a
trailer except the towing (other than for reward) of any one disabled mechanically propelled vehicle.
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Drivers Clause : Any person including the insured Provided that the person driving holds an effective and valid driving license to drive the category of vehicle insured hereunder, at the time of
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accident and is not disqualified from holding or obtaining such a license. Provided also that a person holding an effective and valid Learner's License to drive the category of vehicle
insured hereunder may also drive the vehicle when not used for transport of passengers at the time of accident and that the person satisfies the requirements of Rule 3 of 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 .
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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".
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UIN : IRDAN058RP0038V01100001
Financier : SELF OWNED
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Prev Policy : Oriental Insurance Company Ltd. (Pol No: 242596/31/2023/tmp/137975 Expiry Date: 26/02/2024)
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Nominee Name : Relation : Age :

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NOTE : Warranted that in case of dishonour of the premium cheque, this document stands automatically cancelled 'AB-INITIO'.
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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.
If such revised premium is not paid then the motor insurance policy will not be valid.
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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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Policy Details Cashless Garages Details

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Authorised Signatory
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For & On behalf of

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National Insurance Company Limited

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NIC/UBPORTAL/9000156288 24/02/2024 12:11 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]