Servicing Office Address

Phagwara Branch,G T Road, Phagwara, Dist: Kapurthala, Punjab, Pin :

144401
GSTIN No: 03AAACN9967E1ZD

RECEIPT

Customer Details Collection Details

Name : Mr VIJAY KUMAR SHARMA Agent Code : 9000143261
Address : S/O SH OM PARKASH SHARMA VILL Collection Number : 40180181208000000297
SHAHPUR TEH PHILLAUR , PUNJAB , Collection Date : 08/08/2020
Pin Code : 144410 Bank Account : 9174

Received with thanks from Sri/Smt Mr VIJAY KUMAR SHARMA

a sum of 4208 (RUPEES FOUR THOUSAND TWO HUNDRED EIGHT ONLY) by CD
towards 1 Year Liability Only Policy as per details given hereunder

Sl Policy Number TR Code End/Ren/Dec/Clm End/Ren/Dec/Clm A/C Particulars A/C Head Credit Amount Debit Amount Amount
No. Year Number (General Ledger) Received

1 40180131206760000147 11 C.D CONTROL A/C 5076 0.00 4208.00 -4208.00

2 40180131206760000147 11 CASH PREMIUM A/C 5083 3566.00 0.00 3566.00

3 40180131206760000147 11 CGST_PB_Int_Liab 7373 321.00 0.00 321.00

4 40180131206760000147 11 SGST_PB_Int_Liab 7374 321.00 0.00 321.00

TOTAL : 4208.00 4208.00 0.00

Particulars : CD

For National Insurance Company Ltd.,

1.Please quote collection no. and date in all correspondeces
2.The stamp has been defaced and retained at the office against the issued
policy.

Authorised Signatory

NIC/UBPORTAL/9000143261 08/08/2020 04:30 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
 Issuing Office Name & Address
PHAGWARA BRANCH ,G T ROAD, PHAGWARA, DIST: KAPURTHALA,
PUNJAB, PIN : 144401
Tel: Fax:
GSTIN No: 03AAACN9967E1ZD

National Insurance Company Ltd.

Registered & Head Office: 3, MIDDLETON STREET, POST BOX NO. 9229, KOLKATA - 700 071
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
Form 51 of the Central Motor Vehicle Rules, 1989
Policy No: 40180131206760000147 1 Year Liability Only from 15:16 Hrs of 08/08/2020 to Midnight of 07/08/2021 IXI
Insured Details
Name : Mr VIJAY KUMAR SHARMA
Address : S/O SH OM PARKASH SHARMA VILL SHAHPUR TEH PHILLAUR , PUNJAB ,
Pincode : 144410 Telephone : 9815487509 Email : sunilpumma@gmail.com
PAN No. : GSTIN No. : Aadhar No. :
Channel : SUNIL SHARMA Mobile : 9815800067 Email : aanchal08107@gmail.com
Aadhar : PAN : xxxxxx890E Code. : 34205 / 9000143261
Vehicle Details
Make & Model Private Car MARUTI SUZUKI SWIFT DZIRE ZXI
Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District
PB-08-EA-0668 K12MN2191086 MA3CZF635JD327068 SEDAN 1197 2018 1+4 JALANDHAR
Geographical Area : INDIA.
Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV
- - - - - -

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

Basic OD Premium Basic TP Premium 3,221.00
(+) Electrical Access. Premium - (+) WC for Driver YES 50.00
(+) Bi-fuel kit Loading - (+) Wider Legal Liability to employees -
(+) Geographical Area Extension - (+) Geographical Area Extension -
(-) Vol. Excess Discount - (+) PA to owner driver YES 295.00
(-) Auto. Assoc Discount - (+) PA to unnamed PAX -
(-) Anti-theft Discount - (-) Discount For Limited TPPD -
(-) Other Discount - (+) Bi-fuel kit Loading -
(-) NCB Discount TP Total (Rounded Off) 3,566.00
(+) Nil Depreciation - OD Total (Rounded Off)
(+) Nil Depreciation Plus - TOTAL PREMIUM 3,566.00
(+) NCB Protect - GST 642.00
(+) Engine Protect - NET PAYABLE 4,208.00
(+) Invoice Protect - Collection Number :40180181208000000297 dated 08-Aug-2020
OD Total (Rounded Off) Subject to IMT Endorsement No. 24,25,28
Excess : Compulsory: Rs. 0 Imposed: Rs. 0 Voluntary: Rs. 0
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
making (e) Speed Testing and Reliability Trials (f) Use in connection with Motor Trade
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
Vehicles Rules, 1989.
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 . PA Cover under section 3 for owner-driver is Rs. 15,00,000.
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 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.
Financier : SELF OWNED
Prev Policy : Not Available
Nominee Name : SURINDER KUMAR Relation : SON Age : 46 Years
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.
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.

Authorised Signatory
For & On behalf of
National Insurance Company Limited

NIC/UBPORTAL/9000143261 08/08/2020 04:30 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