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Servicing Office Address

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Kolencherry Division,First Floor, V/570 G, Ellora Towers, Kolencherry,

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Ernakulam, Kerala, Pin : 682311
GSTIN No: 32AAACN9967E1ZC

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RECEIPT

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Customer Details Collection Details

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Name : Mr JITHIN T K Agent Code : 9000152677

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Address : KALAPURAYIL H MUVATTUPUZHA P O Collection Number : 57150081210000016332
MUVATTUPUZHA KERALA ERNAKULAM , Collection Date : 27/01/2022

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KERALA , Bank Account : 9173

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Pin Code : 686668

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Received with thanks from Sri/Smt Mr JITHIN T K

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a sum of 1235 (RUPEES ONE THOUSAND TWO HUNDRED THIRTY FIVE ONLY) by CD
towards 1 Year Liability Only Policy as per details given hereunder

77
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Sl Policy Number TR Code End/Ren/Dec/Clm End/Ren/Dec/Clm A/C Particulars A/C Head Credit Amount Debit Amount Amount

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No. Year Number (General Ledger) Received

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1 57150031216760012077 11 21 C.D CONTROL A/C 5076 0.00 1235.00 -1235.00
31
2 57150031216760012077 11 CASH PREMIUM A/C 5083 1047.00 0.00 1047.00
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3 57150031216760012077 11 CGST_KL_Int_Liab 7346 94.00 0.00 94.00

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4 57150031216760012077 11 SGST_KL_Int_Liab 7347 94.00 0.00 94.00

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TOTAL : 1235.00 1235.00 0.00

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Particulars : CD
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For National Insurance Company Ltd.,

1.Please quote collection no. and date in all correspondeces
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2.The stamp has been defaced and retained at the office against the issued
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policy.
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NIC/UBPORTAL/9000152677 27/01/2022 08:54 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
 Issuing Office Name & Address
KOLENCHERRY DIVISION , FIRST FLOOR, V/570 G, ELLORA TOWERS,
KOLENCHERRY, ERNAKULAM, KERALA, PIN : 682311
Tel: 0484 2760187 (D) 2760487 (G) , 2760187 Fax:
GSTIN No: 32AAACN9967E1ZC

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

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Policy No: 57150031216760012077 2W 1 Year Liability Only from 00:00 Hrs of 28/01/2022 to Midnight of 27/01/2023 IXI

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Insured Details

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Name : Mr JITHIN T K

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Address : KALAPURAYIL H MUVATTUPUZHA P O MUVATTUPUZHA KERALA ERNAKULAM , KERALA ,

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Pincode : 686668 Telephone : 9496825916 Email : sinibenny6@gmail.com

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PAN No. : GSTIN No. : Aadhar No. :

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Channel : SINI BENNY Mobile : 9946906290 Email : sinibenny6@gmail.com

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Aadhar : PAN : xxxxxx045G Code. : 50868 / 9000152677

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Vehicle Details

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Make & Model Two Wheeler Hero Honda Passion Pro 10 Drum Self Cast

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Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District

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KL-17-H-3360 HA10EDBH21281 MBLHA10EWBHG21087 100 2011 1+1 ERNAKULAM

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Geographical Area : INDIA.

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FastTag ID : .

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Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV

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- - - - - -

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

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Basic OD Premium Basic TP Premium :00 752.00
(+) Geographical Area Extension - (+) Geographical Area Extension -
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(-) Vol. Excess Discount - (+) WC for Driver -

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(-) Auto. Assoc Discount - (+) PA to owner driver YES 295.00

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(-) Anti-theft Discount - (+) PA to unnamed PAX -

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(-) Other Discount - (-) Discount For Limited TPPD -

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(-) NCB Discount TP Total (Rounded Off) 1,047.00

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(+) Nil Depreciation - OD Total (Rounded Off)

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(+) Nil Depreciation Plus - TOTAL PREMIUM 1,047.00

(+) NCB Protect - GST 188.00
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(+) Engine Protect - NET PAYABLE 1,235.00

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(+) Invoice Protect - Collection Number :57150081210000016332 dated 27-Jan-2022

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OD Total (Rounded Off) Subject to IMT Endorsement No. 24,25

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Excess : Compulsory: Rs. 0 Imposed: Rs. 0 Voluntary: Rs. 0

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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
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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
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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.
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Limits of Liability Clause: Under section 1(i) Such amount as is necessary to meet the requirements of the motor vehicle act 1988.
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Under section 1(ii) Damage to third party property is Upto Rs. 1,00,000 . PA Cover under section 3 for owner-driver is Rs. 15,00,000.
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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
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RIGHT OF RECOVERY". For legal interpretation, English version will hold good.
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Financier : SELF OWNED

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Prev Policy : National Insurance Company Limited (Pol No: 57150031196760001916 Expiry Date: 27/01/2022)
Nominee Name : THULASEEDHARAN Relation : FATHER Age : 56 Years
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NOTE : Warranted that in case of dishonour of the premium cheque, this document stands automatically cancelled 'AB-INITIO'.
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Policy stamp to be defaced at the respective policy servicing office.

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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.
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Authorised Signatory
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For & On behalf of

National Insurance Company Limited
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NIC/UBPORTAL/9000152677 27/01/2022 08:54 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