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Servicing Office Address
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Hissar Division,First Floor, S C O 155-156, 21, Commercial Urban Estate,
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Near Telephone Exchage, PB No: 35 , Hissar, Hisar, Haryana, Pin : 125001
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GSTIN No: 06AAACN9967E2Z6
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RECEIPT
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Customer Details Collection Details
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Name : Mr SANJAY KUMAR Agent Code : 9800008786
Address : S/O SH INDER SINGH R/O VILL BHONSLA Collection Number : 42030081238000003005
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TEH UCHANA JIND , HARYANA , JIND Collection Date : 26/01/2024
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Pin Code : 126115 Bank Account : 9174
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Received with thanks from Sri/Smt Mr SANJAY KUMAR
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a sum of 7619 (RUPEES SEVEN THOUSAND SIX HUNDRED NINETEEN 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
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1 42030031236160001553 11 C.D CONTROL A/C 5076 0.00 7619.00 -7619.00
31
2 42030031236160001553 11 CASH PREMIUM A/C 5083 6457.00 0.00 6457.00
55
3 42030031236160001553 11 01
CGST_HR_Int_Liab 7337 581.00 0.00 581.00
00
4 42030031236160001553 11 SGST_HR_Int_Liab 7338 581.00 0.00 581.00
16
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TOTAL : 7619.00 7619.00 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
policy.
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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
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/9800008786 26/01/2024 07:12 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
HISSAR DIVISION ,FIRST FLOOR, S C O 155-156, 21, COMMERCIAL URBAN ESTATE,
NEAR TELEPHONE EXCHAGE, PB NO: 35 , HISSAR, HISAR, HARYANA, PIN : 125001
Tel: Fax: 01662 232656 (D) 237468 (G) , 225653
GSTIN No: 06AAACN9967E2Z6
RSA Service Provider: M/s ki MOBILITY SOLUTIONS PRIVATE LIMITED
RSA Service Provider Toll Free Number :- 1800 570 1906
For feedback to RSA:- Email: rsa.service@tvs.in
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: 42030031236160001553 Private Car 1 Year Package from 19:02 Hrs of 26/01/2024 to Midnight of 25/01/2025 IXI
Policy
Insured Details
Name : Mr SANJAY KUMAR
Address : S/O SH INDER SINGH R/O VILL BHONSLA TEH UCHANA JIND , HARYANA , JIND
Pincode : 126115 Telephone : 9017231123 Email : tichisar@gmail.com
PAN No. : xxxxxx695D GSTIN No. : Aadhar No. : xxxx xxxx 3889
Channel : VIJAY KUMAR Mobile : 8642000057 Email : sainvijay69@gmail.com
Aadhar : PAN : xxxxxx805H Code. : 873873 / 9800008786
Break-in Approver : RAJBIR SINGH PUNIA(23306)
Vehicle Details
Make & Model Private Car MARUTI SUZUKI RITZ VDI BS-IV
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Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District
02
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HR-31-J-3155 D13A2253322 DEB1S00472476 HATCHBACK 1248 2014 1+4 JIND
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Geographical Area : INDIA.
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Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV
of
Rs.2,00,000 - - - - Rs.2,00,000
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OD Premium Breakup in Rs. TP Premium Breakup in Rs.
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Basic OD Premium 6,702.00 Basic TP Premium 3,416.00
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(+) Electrical Access. Premium - (+) WC for Driver YES 50.00
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(+) Bi-fuel kit Loading - (+) Wider Legal Liability to employees -
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(+) Geographical Area Extension - (+) Geographical Area Extension an -
(-) Vol. Excess Discount - (+) PA to owner driver YES 295.00
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(-) Auto. Assoc Discount - (+) PA to unnamed PAX -
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(-) Anti-theft Discount - (-) Discount For Limited TPPD -
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(-) Other Discount - -3,351.00 (+) Bi-fuel kit Loading -
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(-) NCB Discount 20% -670.20 TP Total (Rounded Off) 3,761.00
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(+) Nil Depreciation - OD Total (Rounded Off) 2,696.00
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(+) Nil Depreciation Plus - TOTAL PREMIUM 6,457.00
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(+) NCB Protect - GST 1,162.00
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(+) Engine Protect - NET PAYABLE 7,619.00
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(+) Invoice Protect - Collection Number :42030081238000003005 dated 26-Jan-2024
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(+) Consumables Protect - Subject to IMT Endorsement No. 7,24,25,28
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(+) Motor Daily Allowance -
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(+) Motor Pick & Drop -
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(+) Motor Fuel Flip Flop. -
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(+) Lock-Key Protect - Prem: SI:
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(+) Loss of Personal Belongings - Prem: SI:
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(+) RSA Protect YES 15.00
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OD Total (Rounded Off) 2,696.00
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Excess : Compulsory: Rs.1,000 Imposed: Rs.0 Voluntary: Rs.0
00
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
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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
Vehicles Rules, 1989 as amended from time to time.
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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 as amended from time to time.
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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 as amended from time to time 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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UIN : IRDAN058RP0034V01100001
HYPOTHECATION : INDUSIND BANK LTD
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Prev Policy : United India Insurance Company Ltd. (Pol No: 1104093122P109383612 Expiry Date: 19/12/2023)
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Nominee Name : INDER SINGH Relation : FATHER Age : 65 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.
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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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NIC/UBPORTAL/9800008786 26/01/2024 07:12 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: customer.support@nic.co.in
Issuing Office Name & Address
HISSAR DIVISION ,FIRST FLOOR, S C O 155-156, 21, COMMERCIAL URBAN ESTATE,
NEAR TELEPHONE EXCHAGE, PB NO: 35 , HISSAR, HISAR, HARYANA, PIN : 125001
Tel: Fax: 01662 232656 (D) 237468 (G) , 225653
GSTIN No: 06AAACN9967E2Z6
RSA Service Provider: M/s ki MOBILITY SOLUTIONS PRIVATE LIMITED
RSA Service Provider Toll Free Number :- 1800 570 1906
For feedback to RSA:- Email: rsa.service@tvs.in
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
Authorised Signatory
For & On behalf of
National Insurance Company Limited
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