ORIGINAL FOR RECIPIENT/DUPLICATE FOR SUPPLIER.

TAX INVOICE/CERTIFICATE CUM POLICY SCHEDULE

(FORM 51 OF THE CENTRAL MOTOR VEHICLES RULES, 1989)
Policy Type Stand-alone OD Policy ( Private Vehicle ) Proposal No. & Date SR21957318 / 29-Apr-2025
Policy No. & Type D200055695 Period of Insurance 02-May-2025 to 01-May-2026
Policy Issued On 29-Apr-2025 (00:00) Vehicle Identification No. MA3RYHL1SPD232433
Insured Name Mr. Sumit Kumar Geographical Area INDIA
Invoice No IA176513794 Accounting Code of Service 997134
Insured Address S/O-RAMLAKHAN PANJIYARA-GRAM-BARMANIYA, POST+P.S - BOUNSI Bounsi BANKA,
BANKA-813104, Bihar
Insured State & Code Bihar-10 Place of Supply Bihar GSTIN of Customer GSTUNREGISTERED
INSURED MOTOR VEHICLE DETAILS INSURED DECLARED VALUE (IDV) (in Rs.)
Make Maruti Vehicle 773150
Model & Variant NEW BREZZA K15C ISG 5MT ZXI BS6/MARUTI BREZZA SMART HYBRID ZXI 1.5L 5MT Non Electrical Accessories 0
Registration No BR10AN4177 Electrical Accessories 0
Year of Manufacture 2023 CNG/ LPG Kit 0
Engine- Chassis No K15CN 7134084 - MA3RYHL1SPD232433 Total IDV 773150
Cubic Capacity 1462
Seating Capacity 5
Type Of Body Saloon
RTO Location BR10AN4177 / BHAGALPUR
Schedule Of Premium (Amount in Rs.)
OWN DAMAGE SECTION (A) Pre-Existing Third Party Policy Details.
Vehicle 5180 Insurance Company Name ICICI LOMBARD GENERAL INSURANCE CO LTD
Elec. Accessories 0 Policy No. 3001/MI-12111937/00/000
Non- Elec. Accessories 0 Risk Inception Date 02-May-2023
Kit (IMT-25) 0 Risk Expiry Date 01-May-2026
Extra Premium towards Inbuilt CNG/LPG NA
Basic Premium 5180 Point of Sale - Seemanchal Motors Pvt. Ltd., PURNEA
Geographical Area Extn. (IMT-1) NA
Lamp, Tyres etc. (IMT 23) 0
Notes : ( For Stand-alone OD Policy )
Driving Tuition Loading On OD Premium (60%) NA
Fiber Glass Tank 0 1. Policy Issuance is the subject to the realisation of cheque.
Sub-Total Additions 0 2. Consolidate stamp duty paid to State Exchequer
Deductibles 3. The Policy is subject to a compulsory Deductible of Rs 1000 (IMT -22)
4. Voluntary excess Rs (0)
Voluntary Deductibles (IMT 22A) 0 5. Subject to Endorsements IMT 10,
Anti-Theft Device (IMT-10) 130 6. As per your declaration to opt out of Compulsory PA Cover due to no valid Driving Licence with the
AAI Membership (IMT-8) 0 Owner-Driver / Alternate PA/Stand-alone CPA policy with minimum Sum Insured of 15 Lakhs , the PA
No Claim Bonus (25%) 1263 cover will not be applicable under this policy.
Discount for vehicles designed for handicapped NA 7. The Coverage under this policy is only for Own Damage and no other liability in connection with
the vehicle.
Sub - Total Deductibles 1393 8. This policy provides the benefit of Roadside Assistance. In case of any emergency, please contact
Add - On Coverages on below number. -
DEPRECIATION PROTECT 3479 Toll Free: - 1800-258-5956
9. OD Premium rates are different for NCB/Non-NCB class of customer. In case of change from NCB to
Engine And Gear Box Protect 0 Non-NCB, the recoverable amount may be more than the NCB amount.
Return To Invoice 0
BREAKDOWN ASSISTANCE 20
Net own Damage Premium (A) 7286
CGST@9% 655.74
SGST@9% 655.74
Total OD Premium 8597
Nominee Details : Nominee Name MINA DEVI Age 65 Relation Mother
Payment Method Cheque No./Transaction No. Bank Name Amount
Payment Detail
Auto Debit 55507383 HSBC BANK LTD 8922
Financier Type Not Financed Financier Name NA Financier Branch NA
Limitations 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 making, e) Speed
testing, f) Reliability Trials, g) Any purpose in connection with Motor Trade.
Driver: Any person including the insured, Provided that a person driving holds an effective driving license at the time of the accident and is not disqualified from holding or obtaining such a license; Provided also that the
person holding an effective learner's license may also drive the vehicle and that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
Deductibles: Deductible under section-I : Rs 1000(Compulsory Deductible Rs 1000 Imposed Deductible Rs. 0 and Voluntary Deductible Rs 0)
No Claim Bonus: The insured is entitled for a No Claim Bonus (NCB) on the Own Damage section of the policy, if no claim is made or pending during the preceding year (s), as per the following: The preceding year/20%,
Preceding Two consecutive years/25%, Preceding Three consecutive years/35%, Preceding Four consecutive years/45%, Preceding Five consecutive years/50%. No Claim Bonus will only be allowed provided the policy
is renewed within 90 days of the expiry date of the previous policy.
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 reason of wider terms appearing in the
Certificate in order to comply with the Motor Vehicle 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.
For information on ombudsman you may visit website : https://www.cioins.co.in/Ombudsman
I / We hereby certify that the Policy to which this Certificate relates as well as this Certificate of Insurance are issued in accordance with the provisions of Chapter X and Chapter XI of M.V. Act, 1988.
For Go Digit General Insurance Ltd.

Authorized Signatory
Policy Issuing Office:-No 509, Patna One Mall, Dak Bunglow Chowk, Patna, Bihar - 800001
GSTIN: 10AACCO4128Q1ZF, CIN No.:U66010PN2016PLC167410
State Name : Bihar