Hero GoodLife Program Online Acknowledgement cum Declaration Receipt

Dealer Code Dealer Name Card No. VIN No. Group Policy Number Date & Time of Enrollment Enrolment Ref. No.
11071 Sai Swarna Motors 1107120550001187 MBLHAW101L5J88391 355100422010000149 23 Oct 2020 03:10:00 PM 16941008

I Jakku Mangarao S/o Tirupatayya do hereby acknowledge and declare as under:

I understand & accept the 'Hero GoodLife Program' and I have received a copy of its terms & conditions.
I being interested to become a member of 'Hero GoodLife Program' have provided my personal details/other
information for the same.
I have opted for one (1) year insurance cover of 'Group Personal Accident Policy' issued by the National Insurance
Company Limited under Hero GoodLife Program and have paid membership fee of Rs.299/‐ for the program.
On becoming 'Hero GoodLife Program' member, any information about various activities and/or important
developments under the said program; may be sent to me from time to time; by any means of communications and
in any language, at the sole discretion of Hero MotoCorp Ltd.
In the event of my accidental death and being eligible / covered under 'Group Personal Accident Policy' by National
Insurance Company LTD., I hereby nominate and assign the amount payable under the policy to Mr. / Ms. Sivamma,
who is my Mother and presently residing at Ankalagudem, Koyyalagudem, West Godavari, Andhra Pradesh, 534312. I
declare that on said nominee's claiming and receiving insurance amount under 'Group Personal Accident Policy', the
same shall be the full & final discharge of claim for National Insurance Co Ltd and Hero MotoCorp Ltd. shall not be
liable for any claim, whatsoever.
In case of accidental death immediate notice should be given (preferably within 60 days) to the nearest Hero
MotoCorp dealer or Hero GoodLife Program Centre. For prompt claim settlement documents (mainly Hero
GoodLife Card copy, copy of Acknowledgement cum Declaration Receipt, Claim Form, attested copies of FIR, PMR,
Death certificate, Hospitalisation papers etc.) are to be submitted as early as possible. In case of regional language
documents please submit translated copies.
If you need any help please contact us at the following helpline number :‐ 18002660018

This is a computer generated statement and does not require any signature.
 Certificate of Membership under Master Policy
Master Policy No: 355100422010000149 VIN No: MBLHAW101L5J88391
Card No: 1107120550001187

Name and Address of the Group Organizer/Group Policy holder The Grand Plaza,Plot No.2,Nelson Mandela Road,Vasant Kunj,Phase-
II,New Delhi-110070

Name, Code and Address of the Issuing Dealer Sai Swarna Motors, (Code-11071), 58/1, NARASIMHA RAO
PETA,BESIDES NEW RTC BUS STAND,G N T ROAD,ELURU,ANDHRA
PRADESH-534001

Period of Insurance: 23 Oct 2020 15:10:00 to 23 Oct 2021

Insured Details
Name Address DOB/Age Gender Mobile No Email ID
Jakku Ankalagudem Koyyalagudem Jangareddygudem 04 Apr
Male 7287931104 mangarao@gmail.com
Mangarao Andhra Pradesh 534312 1984

Nominee Details
Relationship
Name Address DOB/Age Gender
with Insured
Sivamma Ankalagudem, Koyyalagudem, West Godavari, Andhra Pradesh, 534312 Mother

Sum Insured Details

Peril Sum(in INR)
Death 1,00,000

Please quote the Master Policy No., Vin no.& Card no. in all your correspondence.
IN WITNESS WHEREOF, this Policy of Insurance has been signed on 23/10/2020 .

For National Insurance Company Limited

S/D

Duly Authorized Signatory

Policy Coverage

Death only, arising out of accident as per terms and conditions, exclusions and exemptions of the standard Group Personal Accident Policy (Refer to Annexure-1).

Documents required at the time of lodging claim

Claim Intimation Letter (Immediate claim intimation may be sent at above address or mail at 3551OO@nic.co.in or incharge.3551OO@nic.co.in)
Policy Acknowledgement copy/Certificate of membership under Master policy
Goodlife card(Along with deceased 's Govt ID like PAN Card/ Aadhar Card/ Voter ID card/ driving Licence)
Claim form duly signed by the nominee
FIR(Attested and translated in English/Hindi if in regional language)
Final police report( Attested, if applicable)
Post Mortem Report (Attested and translated in English/Hindi if in regional language)
ChemicalNiscera Report (If Applicable)
Death Certificate(Attested and translated in English/Hindi if in regional language)
Nominee Bank details((Along with KYC Details-Photograph, PAN Card, Aadhar Card)
 Hero MotoCorp Limited
The Grand Plaza,Plot No.2,Nelson Mandela Road,Vasant Kunj,Phase-II,New Delhi-110070
GSTIN/Unique ID: 07AAACH0812J1ZY
PAN: AAACH0812J

TAX INVOICE

INV Serial No.: 11071GL102016941008 Invoice Date: 23 Oct 2020 ORIGINAL FOR RECIPIENT
Dealer Code: 11071 DUPLICATE FOR SUPPLIER

Customer Details
Name : Jakku Mangarao
Address : Ankalagudem Koyyalagudem Jangareddygudem Andhra Pradesh 534312
State : Andhra Pradesh
State code : 37
GSTIN/Unique ID(if any) : N/A
PAN No : N/A
Place Of Supply : Delhi
Rate CGST SGST/UTGST IGST
Sr. HSN Taxable
Description of Goods/Services Qty. Unit (per Total Discount
No. Code Value Rate(%) Amt Rate(%) Amt Rate(%) Amt
unit)

Hero Goodlife(Silver) Membership Fees 1Yr

1 9985 1 Nos 253.39 253.39 NIL 253.39 18 45.61
Insurance

Total 253.39 45.61

Total Taxable Value 253.39

Total GST Charged 45.61
Total Invoice Value (In Words)
Rs. Two Hundred Ninety Nine Only Total Invoice Value (In figure) 299.00
Less : Promotional Discount 0.00
Round Off 0.00

Amount of Tax subject to Reverse Charges NIL Amount Payable 299.00

This is a computer generated statement and does not require any signature.