24

-20
un
Servicing Office Address

4- J
Samastipur Business Office,2nd Floor, Jagannath ComplexMohanpur Road,

n1
Near Chandana Petrol PumpSamastipurSamastipur

so
GSTIN No: 10AAACN9967E3ZG

ur
Ho
RECEIPT

:01
Customer Details Collection Details

:00
Name : Mr ANAND KUMAR Agent Code : 9800008031

00
Address : S/O-LT-MAHAVIR LAL SWAROOP NAGAR KH Collection Number : 17120081248000004184

m
NO-41/4 , 41/5 BLOCK NORTHWEST DELHI Collection Date : 11/06/2024

ro
,A/P-STATION ROAD SAMASTIPUR , BIHAR , Bank Account : 9173

yf
Pin Code : 848101

lic
Po
Received with thanks from Sri/Smt Mr ANAND KUMAR

ge
a sum of 10704 (RUPEES TEN THOUSAND SEVEN HUNDRED FOUR ONLY) by CD

ka
towards 1 Year Package Policy Policy as per details given hereunder

ac
Sl Policy Number TR Code End/Ren/Dec/Clm End/Ren/Dec/Clm A/C Particulars A/C Head Credit Amount Debit Amount Amount

rP
No. Year Number (General Ledger) Received

a
Ye
91
1 17120031246160002069 11 C.D CONTROL A/C 5076 0.00 10704.00 -10704.00

06
2 17120031246160002069 11 CASH PREMIUM A/C 5083 9072.00 0.00 9072.00
02
00
3 17120031246160002069 11 CGST_BR_Int_Liab 7313 816.00 0.00 816.00
16

4 17120031246160002069 11 SGST_BR_Int_Liab 7314 816.00 0.00 816.00

46
12

TOTAL : 10704.00 10704.00 0.00

03
20

Particulars : CD
71
:1

For National Insurance Company Ltd.,

No

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

2.The stamp has been defaced and retained at the office against the issued
cy

policy.
oli

3.We hereby declare that though our aggregate turnover in any preceding
. P

financial year from 2017-18 onwards is more than the aggregate turnover
notified under sub-rule (4) of rule 48, we are not required to prepare an invoice
td

in terms of the provisions of the said sub-rule.

L
ny
pa
om

Authorised Signatory
eC
nc
ra
su
l In
na
tio
Na

NIC/UBPORTAL/9800008031 11/06/2024 09:44 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
 Issuing Office Name & Address
SAMASTIPUR BUSINESS OFFICE ,2ND FLOOR, JAGANNATH COMPLEXMOHANPUR
ROAD, NEAR CHANDANA PETROL PUMPSAMASTIPURSAMASTIPUR
Tel: Fax: 222659 (G) , 227339
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 as amended from time to time
Policy No: 17120031246160002069 Private Car 1 Year Package from 00:00 Hrs of 14/06/2024 to Midnight of 13/06/2025 IXI
Policy
Insured Details

Name : Mr Amit Singh

Address : S/O-LT-MAHAVIR LAL SWAROOP NAGAR KH NO-41/4 , 41/5 BLOCK NORTHWEST DELHI ,A/P-STATION ROAD SAMASTIPUR , BIHAR ,
Pincode : 848101 Telephone : 9162520999 Email : [email protected]
PAN No. : GSTIN No. : Aadhar No. : xxxx xxxx 1157
Channel : ANITA DEVI Mobile : 9471644203 Email : [email protected]
Aadhar : PAN : xxxxxx063R Code. : 171200 / 9800008031
Vehicle age>10 Years Approver : RANJEET KUMAR(71635)
Vehicle Details
Make & Model Private Car MARUTI SUZUKI SWIFT DZIRE VXI LIMITED EDITION

5
Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District

02
6/2
DL-2-CAS-0539 58070 18525 SEDAN 1197 2013 1+4 CENTRAL DELHI

3/0
Geographical Area : INDIA.

f1
Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV

to
Rs.1,63,588 Rs.15,000 Rs.15,000 - - Rs.1,93,588

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

idn
Basic OD Premium 6,302.37 Basic TP Premium 3,416.00

oM
(+) Electrical Access. Premium YES 600.00 (+) WC for Driver YES 50.00

t
24
(+) Bi-fuel kit Loading - (+) Wider Legal Liability to employees -

20
(+) Geographical Area Extension - (+) Geographical Area Extension -
n-
-Ju
(-) Vol. Excess Discount - (+) PA to owner driver -
14

(-) Auto. Assoc Discount - (+) PA to unnamed PAX ( 4 No. x Rs. 2,00,000 ) YES 400.00
on

(-) Anti-theft Discount - (-) Discount For Limited TPPD -

s

(-) Other Discount - -414.14 (+) Bi-fuel kit Loading -

ur
Ho

(-) NCB Discount 20% -1,297.65 TP Total (Rounded Off) 3,866.00

:01

(+) Nil Depreciation - OD Total (Rounded Off) 5,206.00

:00

(+) Nil Depreciation Plus - TOTAL PREMIUM 9,072.00

00

(+) NCB Protect - GST 1,632.00

m

(+) Engine Protect - NET PAYABLE 10,704.00

ro

(+) Invoice Protect - Collection Number :17120081248000004184 dated 11-Jun-2024

yf
lic

(+) Consumables Protect - Subject to IMT Endorsement No. 16,24,25,28

Po

(+) RSA Protect YES 15.00

ge

OD Total (Rounded Off) 5,206.00

ka

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

ac

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
rP

making (e) Speed Testing and Reliability Trials (f) Use in connection with Motor Trade
ea

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
1Y

Vehicles Rules, 1989 as amended from time to time.

Limits of Liability Clause: Under section 1(i) Such amount as is necessary to meet the requirements of the motor vehicle act 1988 as amended from time to time.
69

Under section 1(ii) Damage to third party property is Upto Rs. 7,50,000 .
20

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
appearing in the certificate in order to comply with the Motor Vehicles Act,1988 as amended from time to time is recoverable from the insured .See the clause headed
00

"AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY". For legal interpretation, English version will hold good.
60

UIN : IRDAN058RP0034V01100001
61

Financier : SELF OWNED

24

Prev Policy : National Insurance Company Limited (Pol No: 17120031236160002014 Expiry Date: 13/06/2024)
31

NOTE : Warranted that in case of dishonour of the premium cheque, this document stands automatically cancelled 'AB-INITIO'.
00

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.
12

The Insured should contact and submit the difference of premium to the policy issuing office on issuance of such notification by IRDAI.
17

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 as amended from time to time.
:

Policy Details Cashless Garages Details

yNo
lic

Authorised Signatory
Po

For & On behalf of

National Insurance Company Limited
d.
Lt
ny
pa
om
eC
nc
ra
su
l In
na
tio
Na

NIC/UBPORTAL/9800008031 11/06/2024 09:44 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]