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Servicing Office Address

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Azamgarh Branch,434, Thandi Sadak, Rahul Nagar, Azamgarh, Uttar

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Pradesh, Pin : 276001

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GSTIN No: 09AAACN9967E1Z1

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RECEIPT

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Customer Details Collection Details

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Name : Mr ZAHID Agent Code : 9000156225

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Address : MANDAY JAHANAGANJ SADAR AZAMGARH Collection Number : 45210381238000005681

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, UTTAR PRADESH , AZAMGARH Collection Date : 28/07/2023
Pin Code : 275101 Bank Account : 9174

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Received with thanks from Sri/Smt Mr ZAHID

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a sum of 842 (RUPEES EIGHT HUNDRED FORTY TWO ONLY) by CD
towards 1 Year Liability Only Policy as per details given hereunder

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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
No. Year Number (General Ledger) Received

41
14
03
1 45210331236760003144 11 C.D CONTROL A/C 5076 0.00 842.00 -842.00

00
2 45210331236760003144 11 CASH PREMIUM A/C 5083 714.00 0.00 714.00
76
36
3 45210331236760003144 11 CGST_UP_Int_Liab 7397 64.00 0.00 64.00
12

4 45210331236760003144 11 SGST_UP_Int_Liab 7398 64.00 0.00 64.00

33

TOTAL : 842.00 842.00 0.00

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21
45

Particulars : CD
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For National Insurance Company Ltd.,

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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.
3.We hereby declare that though our aggregate turnover in any preceding
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financial year from 2017-18 onwards is more than the aggregate turnover
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notified under sub-rule (4) of rule 48, we are not required to prepare an invoice
Authorised Signatory
in terms of the provisions of the said sub-rule.
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NIC/UBPORTAL/9000156225 28/07/2023 05:39 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
 Issuing Office Name & Address
AZAMGARH BRANCH , 434, THANDI SADAK, RAHUL NAGAR, AZAMGARH, UTTAR
PRADESH, PIN : 276001
Tel: 05462 - 247450 (G) , 221597 Fax:
GSTIN No: 09AAACN9967E1Z1

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: 45210331236760003144 2W 1 Year Liability Only from 17:37 Hrs of 28/07/2023 to Midnight of 27/07/2024 IXI
Insured Details

4
Name : Mr ZAHID

02
Address : MANDAY JAHANAGANJ SADAR AZAMGARH , UTTAR PRADESH , AZAMGARH

7/2
Pincode : 275101 Telephone : 8543875446 Email : sy8189132@gmail.com

7/0
PAN No. : GSTIN No. : Aadhar No. :

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Channel : RUBI SINGH Mobile : 9838680281 Email : santossinghrto@gmail.com

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Aadhar : PAN : xxxxxx611M Code. : 452103 / 9000156225

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Vehicle Details

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Make & Model Two Wheeler Honda CD 110 CD 110 DREAM DLX CARRIER-BSVI

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

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UP-54-AA-2226 JC67E84017736 ME4JC677EH8015492 110 2017 1+1 MAU

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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

28
- - - - - -

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

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Basic OD Premium Basic TP Premium 714.00

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(+) Geographical Area Extension - (+) Geographical Area Extension :57 -
(-) Vol. Excess Discount - (+) WC for Driver -
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(-) Auto. Assoc Discount - (+) PA to owner driver -

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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) 714.00

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

(+) Nil Depreciation Plus - TOTAL PREMIUM 714.00
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(+) NCB Protect - GST 128.00

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(+) Engine Protect - NET PAYABLE 842.00

(+) Invoice Protect - Collection Number :45210381238000005681 dated 28-Jul-2023
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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

44

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
31

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.
60

Limits of Liability Clause: Under section 1(i) Such amount as is necessary to meet the requirements of the motor vehicle act 1988.
67

Under section 1(ii) Damage to third party property is Upto Rs. 1,00,000 .
23

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
31

RIGHT OF RECOVERY". For legal interpretation, English version will hold good.
UIN : IRDAN058P0036V01100001
03

Financier : SELF OWNED

21

Prev Policy : Not Available

45

Nominee Name : Relation : Age :

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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.
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TP Rate Revision Notice: For all policies having an effective date on or after 1st April 2023, the TP premium is subject to revision as may be notified by the IRDAI.
The Insured should contact and submit the difference of premium to the policy issuing office on issuance of such notification by IRDAI.
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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

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National Insurance Company Limited

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NIC/UBPORTAL/9000156225 28/07/2023 05:39 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