Servicing Office Address

Bhubaneswar Division I,Fourth Floor, IDCO Towers, Janpath, Sahid Nagar,

Bhubaneshwar, Khordha, Odisha, Pin : 751022
GSTIN No: 21AAACN9967E2ZE

RECEIPT

Customer Details Collection Details

Name : Mr AJIT PATRA Agent Code : 9000194957
Address : PLOT NO -212,SASTRI NAGAR, UNIT-4, Collection Number : 16320081210000000543
BBSR , ODISHA , BHUBANESWAR , ODISHA , Collection Date : 24/05/2021
Pin Code : 751001 Bank Account : 9172

Received with thanks from Sri/Smt Mr AJIT PATRA

a sum of 13050 (RUPEES THIRTEEN THOUSAND FIFTY ONLY) by CD
towards 1 Year Package Policy 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 16320031216160000327 11 C.D CONTROL A/C 5076 0.00 13050.00 -13050.00

2 16320031216160000327 11 CASH PREMIUM A/C 5083 11060.00 0.00 11060.00

3 16320031216160000327 11 CGST_OD_Int_Liab 7370 995.00 0.00 995.00

4 16320031216160000327 11 SGST_OD_Int_Liab 7371 995.00 0.00 995.00

TOTAL : 13050.00 13050.00 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/9000194957 24/05/2021 05:14 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
 Issuing Office Name & Address
BHUBANESWAR DIVISION I ,FOURTH FLOOR, IDCO TOWERS, JANPATH,
SAHID NAGAR, BHUBANESHWAR, KHORDHA, ODISHA, PIN : 751022
Tel: Fax: 2543077, 2545267
GSTIN No: 21AAACN9967E2ZE

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: 16320031216160000327 1 Year Package Policy from 00:00 Hrs of 28/05/2021 to Midnight of 27/05/2022 IXI
Insured Details
Name : Mr AJIT PATRA
Address : PLOT NO -212,SASTRI NAGAR, UNIT-4, BBSR , ODISHA , BHUBANESWAR , ODISHA ,
Pincode : 751001 Telephone : 9861271044 Email : asitpatra212@gmail.com
PAN No. : GSTIN No. : Aadhar No. :
Channel : AKHIL KUMAR BHOL Mobile : 9853767390 Email : akhilkumarbhol88@gmail.com
Aadhar : PAN : xxxxxx751R Code. : 163200 / 9000194957
Vehicle Details
Make & Model Private Car MARUTI SUZUKI SWIFT VXI
Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District
OD-02-AW-0550 K12MN7235301 MBHCZC63SJD171836 HATCHBACK 1197 2018 1+4 BHUBANESHWAR
Geographical Area : INDIA.
FastTag ID : .
Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV
Rs.4,23,000 - - - - Rs.4,23,000

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

Basic OD Premium 9,517.50 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 -
(-) Auto. Assoc Discount - (+) PA to unnamed PAX -
(-) Anti-theft Discount YES -237.94 (-) Discount For Limited TPPD -
(-) Other Discount - -3,479.84 (+) Bi-fuel kit Loading -
(-) NCB Discount 35% -2,029.90 TP Total (Rounded Off) 3,271.00
(+) Nil Depreciation - OD Total (Rounded Off) 7,789.00
(+) Nil Depreciation Plus YES 3,173.00 TOTAL PREMIUM 11,060.00
(+) NCB Protect YES 846.00 GST 1,990.00
(+) Engine Protect - NET PAYABLE 13,050.00
(+) Invoice Protect - Collection Number :16320081210000000543 dated 24-May-2021
OD Total (Rounded Off) 7,789.00
Excess : Compulsory: Rs.1,000 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 .
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 : National Insurance Company Limited (Pol No: 16320031206160000243 Expiry Date: 27/05/2021)
Nominee Name : Relation : Age :
In consideration of payment of additional premium as indicated in the Schedule it is hereby agreed and understood that indemnification in respect of Partial loss claims shall be done without application of
Depreciation as mentioned in Section 1. of the policy.
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/9000194957 24/05/2021 05:14 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