पृषांकन /Endorsement -Motor - Private Car

- Package
पॉिलसी संखया/Policy Number : जारीकतार कायारलय/Issuing Office
16370031256160000234 कायारलय कोड /Office Code : 163700
कायारलय पता / Office Address :
BHUBANESHWAR BUSINESS OFFICEII
Plot No 267/1008, A N Plaza, Rasulgarh,
Bhubaneshwar,Dist: Khordha, Odisha, -
ववसाय सोत/ Business Source : 9800001394
751010.
State Code: 21 , Odisha
जीएसटीआईएन / GSTIN: 21AAACN9967E2ZE
संपकर संखया / Contact Number: 674 2586618
िवकय चैनल संपकर नमबर/ Sales Channel
Contact Number : 8249711607
UIN No:
िवकय चैनल का नाम/ Sales Channel Name : Mrs कसटमर के यर टॉल फी नंबर/Customer Care Toll Free
Shradhanjali Bastia Number:1800 345 0330
ईमेल/email:customer.support@nic.co.in
9920501906

गाहक का नाम/Customer Name: MR गाहक आईडी/ Customer ID: 9578089745 पैन/ PAN:
CHITARANJAN DAS
पता/ Address: S/O- RAMANATH DAS, HARADANGA, फोन/ Phone: ********86
HARADANGA, HARADANGA, GANJAM, शहर/City : GANJAM -
DISTRICT OTHERS, िजला/District : GANJAM, राजय/State :
ई-मेल/ E-Mail:******01@NIC.CO.IN
ODISHA, िपन/ PIN : 761008.
मोबाइल/Mobile : ********86
Policy Effective from 12:35 hours, on 06/04/2025 to midnight of 05/04/2026
Premium: ` 6,500.00 Total IDV: ` 4,23,000.00
CGST ` 585.00
SGST/UTGST ` 585.00 25040616370060000008 Dt.
Proposal Number and Date:
IGST ` 0.00 06/04/2025
Kerala Flood Cess ` 0.00
Recoverable Stamp Duty: ` 0.00 Receipt Number: 163700812580000002820000000001
Total Amount: ` 7,670.00 Receipt Date: 06/04/2025
(Rupees Seven Thousand Six Hundred Seventy
Co-Insurance Details: N/A
Only.)
Endorsement Effective from 12:16 hours,on 17/07/2025 to midnight of 05/04/2026
Additional Premium: ` 0.00 Insured's Request Date: 17/07/2025
CGST ` 5.00
SGST/UTGST ` 5.00
Endorsement Number: 163700312582100262
IGST ` 0.00
Kerala Flood Cess ` 0.00

Recoverable Stamp Duty: Endorsement Issue Date: 17/07/2025

`0.00
Total Amount*: ` 60.00 Receipt Number: 163201812510000926
(Rupees Sixty Only.) Receipt Date: 17/07/2025
* Transfer Fee: ` 50.00

General / Common Information change

It is hereby understood and agreed that as from 17-07-25 the interest in the policy is transferred to and vested in

Customer ID: 9578089745 Customer Name: CHITARANJAN DAS

who shall be deemed to be the insured and whose proposal and declaration shall be deemed to be incorporated in and to be the basis of
this contract.

In consequence of which, an additional premium of 60 is hereby charged to the Insured.

It is also agreed and declared that the said vehicle is hypothecated to

िदनांक को मुिदत/Printed on 17/07/2025 आईडी के दारा/by ID: 74441, सहायता/AID : पृष सं./Page no: 1
73498
पृषांकन /Endorsement -Motor - Private Car
- Package
पॉिलसी संखया/Policy Number : जारीकतार कायारलय/Issuing Office
16370031256160000234 कायारलय कोड /Office Code : 163700
कायारलय पता / Office Address :
BHUBANESHWAR BUSINESS OFFICEII
Plot No 267/1008, A N Plaza, Rasulgarh,
Bhubaneshwar,Dist: Khordha, Odisha, -
ववसाय सोत/ Business Source : 9800001394
751010.
State Code: 21 , Odisha
जीएसटीआईएन / GSTIN: 21AAACN9967E2ZE
संपकर संखया / Contact Number: 674 2586618
िवकय चैनल संपकर नमबर/ Sales Channel
Contact Number : 8249711607
UIN No:
िवकय चैनल का नाम/ Sales Channel Name : Mrs कसटमर के यर टॉल फी नंबर/Customer Care Toll Free
Shradhanjali Bastia Number:1800 345 0330
ईमेल/email:customer.support@nic.co.in
9920501906

TATA CAPITAL LTD.

Subject otherwise to the Terms, Exclusion and Conditions of this Policy.

IN CASE OF DISHONOUR OF THE PREMIUM CHEQUE, THIS DOCUMENT STANDS AUTOMATICALLY CANCELLED 'AB-INITIO'

For and On Behalf Of National Insurance Company Limited

Authorized Signatory

िदनांक को मुिदत/Printed on 17/07/2025 आईडी के दारा/by ID: 74441, सहायता/AID : पृष सं./Page no: 2
73498
पृषांकन /Endorsement -Motor - Private Car
- Package
पॉिलसी संखया/Policy Number : जारीकतार कायारलय/Issuing Office
16370031256160000234 कायारलय कोड /Office Code : 163700
कायारलय पता / Office Address :
BHUBANESHWAR BUSINESS OFFICEII
Plot No 267/1008, A N Plaza, Rasulgarh,
Bhubaneshwar,Dist: Khordha, Odisha, -
ववसाय सोत/ Business Source : 9800001394
751010.
State Code: 21 , Odisha
जीएसटीआईएन / GSTIN: 21AAACN9967E2ZE
संपकर संखया / Contact Number: 674 2586618
िवकय चैनल संपकर नमबर/ Sales Channel
Contact Number : 8249711607
UIN No:
िवकय चैनल का नाम/ Sales Channel Name : Mrs कसटमर के यर टॉल फी नंबर/Customer Care Toll Free
Shradhanjali Bastia Number:1800 345 0330
ईमेल/email:customer.support@nic.co.in
9920501906

ANNEXURE I– List of Applicable Clauses

The Following Clauses Included while Endorsement
• IMT 7

• IMT 28

• IMT 22

कृ ते नेशनल इनशयोरेनस कं पनी िलिमटे ड/

For and on behalf of National Insurance Company
Limited

अिधकृ त हसतातकरकतार/ Authorized Signatory

िदनांक को मुिदत/Printed on 17/07/2025 आईडी के दारा/by ID: 74441, सहायता/AID : पृष सं./Page no: 3
73498
पृषांकन /Endorsement -Motor - Private Car
- Package
पॉिलसी संखया/Policy Number : जारीकतार कायारलय/Issuing Office
16370031256160000234 कायारलय कोड /Office Code : 163700
कायारलय पता / Office Address :
BHUBANESHWAR BUSINESS OFFICEII
Plot No 267/1008, A N Plaza, Rasulgarh,
Bhubaneshwar,Dist: Khordha, Odisha, -
ववसाय सोत/ Business Source : 9800001394
751010.
State Code: 21 , Odisha
जीएसटीआईएन / GSTIN: 21AAACN9967E2ZE
संपकर संखया / Contact Number: 674 2586618
िवकय चैनल संपकर नमबर/ Sales Channel
Contact Number : 8249711607
UIN No:
िवकय चैनल का नाम/ Sales Channel Name : Mrs कसटमर के यर टॉल फी नंबर/Customer Care Toll Free
Shradhanjali Bastia Number:1800 345 0330
ईमेल/email:customer.support@nic.co.in
9920501906

CERTIFICATE OF INSURANCE

Form 51 of the Central Motor Vehicle Rules, 1989

Certificate No.: 16370031256160000234 IXI

Particulars of vehicle insured

Reg. Mark, No.
Engine No.& Make, Model Year of Seating
& Place of Type of Body C.C Premium(`)
Chassis No & Variant Manufacture capacity
Registration
HYUNDAI,
GRAND I10
OD-33-S-6573/ G4LAJM813673 NIOS
RTO,BHUBAN MALA851CLJM81 & ASTA AMT 2018 HATCHBACK 5 ` 6,500.00
11971197
ESWAR-II 6883 1.2 KAPPA
VTVT (2020-
2023).

Name of Registration Authority RTO,BHUBANESWAR-II

MR CHITARANJAN DAS,S/O- RAMANATH DAS, HARADANGA,
Name & Address of Insured HARADANGA, HARADANGA, GANJAM,GANJAM - DISTRICT
OTHERS,GANJAM,ODISHA,761008.
Geographical Area India
Business or Profession 999999
From Endorsement Effective Date: 12:16 O' Clock on 17/07/2025 &
Effective date of commencement of Insurance for the purpose of Act.
Policy Effective Date: 12:35 O' Clock on 06/04/2025.
Midnight on : 05/04/2026
Date of expiry of the insurance
.

PERSONS OR CLASS OF PERSONS ENTITLED TO DRIVE

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.

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)Use in connection with Motor Trade.

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.

Full address of Issuing Office: BHUBANESHWAR BUSINESS OFFICEII Plot No For and on behalf of
267/1008, A N Plaza, Rasulgarh, Bhubaneshwar,Dist: Khordha, Odisha, - National Insurance Company Limited
751010

Date of issue: 06/04/2025 Duly Constituted Attorney(s)

िदनांक को मुिदत/Printed on 17/07/2025 आईडी के दारा/by ID: 74441, सहायता/AID : पृष सं./Page no: 4
73498
पृषांकन /Endorsement -Motor - Private Car
- Package
पॉिलसी संखया/Policy Number : जारीकतार कायारलय/Issuing Office
16370031256160000234 कायारलय कोड /Office Code : 163700
कायारलय पता / Office Address :
BHUBANESHWAR BUSINESS OFFICEII
Plot No 267/1008, A N Plaza, Rasulgarh,
Bhubaneshwar,Dist: Khordha, Odisha, -
ववसाय सोत/ Business Source : 9800001394
751010.
State Code: 21 , Odisha
जीएसटीआईएन / GSTIN: 21AAACN9967E2ZE
संपकर संखया / Contact Number: 674 2586618
िवकय चैनल संपकर नमबर/ Sales Channel
Contact Number : 8249711607
UIN No:
िवकय चैनल का नाम/ Sales Channel Name : Mrs कसटमर के यर टॉल फी नंबर/Customer Care Toll Free
Shradhanjali Bastia Number:1800 345 0330
ईमेल/email:customer.support@nic.co.in
9920501906

िदनांक को मुिदत/Printed on 17/07/2025 आईडी के दारा/by ID: 74441, सहायता/AID : पृष सं./Page no: 5
73498
 डेिबट नोट/Debit Note
Details of Supplier:
National Insurance Company Limited.,
BHUBANESHWAR BUSINESS OFFICEII Plot No 267/1008, A N Plaza, Rasulgarh, Bhubaneshwar,Dist: Khordha, Odisha, - 751010
State : 21 , Odisha
GSTIN No : 21AAACN9967E2ZE

Details Of Receiver : MR CHITARANJAN DAS Invoice Serial No: 30094A5EU0100262

Address: Invoice Date: 17/07/2025
S/O- RAMANATH DAS, HARADANGA, HARADANGA, HARADANGA, GANJAM,
ODISHA, Reference to Serial No. of Corresponding
30094A5P60000234
761008. Tax Invoice / Bill of Supply
Reference to Date of the corresponding
06/04/2025
Place of Supply State: Odisha tax invoice / bill of supply
State Code : 21
GSTIN No: NA
GSTIN No:NA

Kerala
Descripti CGST SGST/UTGST IGST Flood
Disco Taxable
SAC Code on of Total(`) Cess
unt Value(`)
Service Amount( Amount(`)
Rate Amount(`) Rate Rate Amount(`)
`)
Motor
vehicle 5 0
997134 0.00 0% 0.00 0% 5 0% 0% 0
insurance
services
TOTAL 0.00 0.00 5 5 0 0
Total Value (In figures) : ` 60
Total Value (In words) : Rupees Sixty Only.
Amount of Tax Subject to Reverse Charge : No

कृते नेशनल इनशयोरे नस कंपनी िलिमटे ड/ For and

on behalf of National Insurance Company Limited
E.&.O.E

अिधकृत हसतातकरकतार/ Authorized Signatory

िदनांक को मुिदत/Printed on 17/07/2025 आईडी के दारा/by ID: 74441, सहायता/AID : पृष सं./Page no: 6
73498