पॉलिसी अनुसूची/ Policy Schedule - Employees Compensation Insurance

Policy Number:
व्यवसाय स्त्रोत /Business Source: 755559
550200412310000010
विक्रय चैनल विवरण/Sales Channel Code:
9000119971
नाम /Name: Mr Sachin Kulkarni Contact
Number: 9701534558
जारीकर्ता कार्यालय/Issuing Office
सह दलाल कोड / Co Broker Code:
कार्यालय कोड /Office Code: 550200
कार्यालय पता /Office Address:
HYDERABAD DIVISION II CSR Plaza,D
No. 6-3-347/9/4,2nd Floor,Dwarakapuri
ColonyPunjagutta,Hyderabad - 500082.
State Code: 36 , Telangana
GSTIN: 36AAACN9967E6ZZ
Contact Number: 40 23401398 कस्टमर केयर टॉल फ्री नंबर/Customer
Mobile Number:
Care Toll Free Number:
1800 345 0330
ईमेल/
email:customer.support@nic.co.in

ग्राहक का नाम /Customer Name: ABS FUJITSU GENERAL PVT ग्राहक आईडी /Customer ID:
पैन /PAN: AAFCA1594D
LTD 9701929002
पता/ Address: H NO. 7-1-214/4, 2ND FLOOR, JANA ARCADE, फोन /Phone:
DHARAM KARAN ROAD, MVR COLONY, AMEERPET,
HYDERABAD, City: HYDERABAD, District: HYDERABAD, State:
TELANGANA, PIN: 500016. ई-मेल /E-Mail: admin.ap@absace.com
Cell: 9830404976

पॉलिसी: 25/07/2023 के 12:00 से 24/07/2024 की मध्य रात्रि तक प्रभावी /Policy Effective from 12:00 hours, on 25/07/2023 to
midnight of 24/07/2024
कवर नोट संख्या और तिथि / Cover
प्रीमियम/ Premium ` 30,098.00 लागू नहीं/NA
Note Number and Date
CGST ` 2,709.00
SGST/UTGST ` 2,709.00
IGST ` 0.00 प्रस्ताव संख्या और तिथि/ Proposal 8800230728873121 Dt. 28/07/2023
कम:जीएसटी_टीडीएस /
Number and Date
` 0.00
Less:GST_TDS
पुनर्प्राप्ति योग्य स्टाम्प
रसीद संख्या और तिथि/ Receipt
ड्यूटी ` 0.00
Number and Date
550200812310001083 Dt. 25/07/2023
/Recoverable Stamp Duty
पिछली पॉलिसी संख्या और समाप्ती
कुल /Total Amount ` 35,517.00 तिथि / लागू नहीं/NA
Previous Policy Number and
Expiry Date
(Rupees Thirty Five Thousand Five Hundred Seventeen Only.)

Joint Policyholder Name: NA

Joint Policyholder Address: NA

Laws: The Policy covers Liability of the Insured under the following Law(s) shown as covered, subject to claim being otherwise admissible
as per terms, conditions and exclusions of the Policy and subject to Limit of Indemnity as stipulated against each Law.

SL.No Law Limit of Indemnity Coverage

Employee Compensation Act, 1923 and
1 Subsequent amendments thereof prior to
the date of issue of this Policy
3 Medical Expenses
Subject otherwise, to the terms, conditions &Exclusions of the
Yes
Policy, the amount of liability incurred by the Insured.
Subject otherwise, to the terms, conditions & Exclusions of the
Policy, the amount of liability incurred by the Insured, but not
exceeding:- Yes
a)Limit Per Employee: `25,000.00
b)Aggregate Limit(AOP): `2,50,000.00

Description of Work Declared

Number of Place of Contractors Name,
SL.No Industry Type Done by Wages/ Contract
Employees Employment Contractors Address
Employees Value

Printed on 31/07/2023 by ID: 56187 Page no: 1

पॉलिसी अनुसूची/ Policy Schedule - Employees Compensation Insurance
Policy Number:
व्यवसाय स्त्रोत /Business Source: 755559
550200412310000010
विक्रय चैनल विवरण/Sales Channel Code:
9000119971
नाम /Name: Mr Sachin Kulkarni Contact
Number: 9701534558
जारीकर्ता कार्यालय/Issuing Office
सह दलाल कोड / Co Broker Code:
कार्यालय कोड /Office Code: 550200
कार्यालय पता /Office Address:
HYDERABAD DIVISION II CSR Plaza,D
No. 6-3-347/9/4,2nd Floor,Dwarakapuri
ColonyPunjagutta,Hyderabad - 500082.
State Code: 36 , Telangana
GSTIN: 36AAACN9967E6ZZ
Contact Number: 40 23401398 कस्टमर केयर टॉल फ्री नंबर/Customer
Mobile Number:
Care Toll Free Number:
1800 345 0330
ईमेल/
email:customer.support@nic.co.in

HRC
Industry
Recreation
Type:Engineers - not
Declared Chambers,
otherwise classified Contractors Name:NA
1 MEP WORKS 15 Wages:2880000 Clubhouse at
Sub Industry Type:incl Contractors Address:NA
Contract Value:0 alijapure,
work away from shop
shaikpet-
or yard
500008
HRC
Industry
Recreation
Type:Engineers - not
Declared Chambers,
otherwise classified Contractors Name:NA
2 MEP WORKS 35 Wages:6300000 Clubhouse at
Sub Industry Type:incl Contractors Address:NA
Contract Value:0 alijapure,
work away from shop
shaikpet-
or yard
500008

Clauses, Endorsements and Warranties Applicable:

Average Clause,
Occupational Diseases

If the monthly wages are lesser than 15000/-, the "Compensation calculation will be based on the actual lesser monthly wages entered and
not Rs 15000/-"

टिप्पणियां/ Remarks: PROJECT - MEP WORKS

PROJECT NAME & LOCATION - HRC Recreation Chambers, Clubhouse at Alijapure, shaikpet-500008.

WORKER DETAILS:
SKILLED - 15
UNSKILLED - 35

The Policy will exclude claims arising out of/due to Covid-19/Communicable diseases and other claims arising out of violation of any
provision of NDMA/Epidemic Act.

जिसकी गवाही में दिन/ माह /वर्ष को उपरोक्त उल्लेखित कार्यालय पते पर अधोहस्ताक्षरी को विधिवत अधिकृत किया जा रहा है उसके हाथ
निर्धारित किए जाएं। यह अनुसूची, संलग्न पॉलिसी, खण्ड, पृष्ठांकन और पॉलिसी शब्दों, जो कंपनी वेबसाईट https://nationalinsurance.nic.co.in
पर उपलब्ध है, को एक अनुबंध के रुप में एक साथ पढ़ा जाए तथा कोई भी शब्द या अभिव्यक्ति जिसके लिए यह विशिष्ट अर्थ पॉलिसी या अनुसूची
के किसी भी हिस्से में संलग्न किया गया हो, एक ही अर्थ वहन करेगा चाहे जहॉ भी उल्लेखित हो। यह आश्वासन दिया जाता है कि प्रीमियम चेक के
अस्वीकृति के मामले में, यह दस्तावेज स्वतः प्राथमिकता निरस्त हो जाएगी । /IN WITNESS WHEREOF, the undersigned being duly authorized
hereunto set his/ her hand at the office address mentioned above, this 31/July/2023.This schedule, the attached policy, the clauses, the
endorsements and policy wordings as available in the website https://nationalinsurance.nic.co.in shall be read together as one contract
and any word or expression to which the specific meaning has been attached in any part of this policy or of the schedule shall bear the same
meaning wherever it may appear. It is warranted that IN CASE OF DISHONOUR OF THE PREMIUM CHEQUE, THIS DOCUMENT STANDS
AUTOMATICALLY CANCELLED 'AB-INITIO'

Printed on 31/07/2023 by ID: 56187 Page no: 2

पॉलिसी अनुसूची/ Policy Schedule - Employees Compensation Insurance
Policy Number:
व्यवसाय स्त्रोत /Business Source: 755559
550200412310000010
विक्रय चैनल विवरण/Sales Channel Code:
9000119971
नाम /Name: Mr Sachin Kulkarni Contact
Number: 9701534558
जारीकर्ता कार्यालय/Issuing Office
सह दलाल कोड / Co Broker Code:
कार्यालय कोड /Office Code: 550200
कार्यालय पता /Office Address:
HYDERABAD DIVISION II CSR Plaza,D
No. 6-3-347/9/4,2nd Floor,Dwarakapuri
ColonyPunjagutta,Hyderabad - 500082.
State Code: 36 , Telangana
GSTIN: 36AAACN9967E6ZZ
Contact Number: 40 23401398 कस्टमर केयर टॉल फ्री नंबर/Customer
Mobile Number:
Care Toll Free Number:
1800 345 0330
ईमेल/
email:customer.support@nic.co.in

कृते नेशनल इन्श्योरेन्स कंपनी

स्टांप ड्यलिमिटे
ूटी ड/ For and on behalf of National Insurance
इंश्योरेन्सइंडियालिमिटेड Stamp Company Limited
Duty:
(` 15.25 ) अधिकृत हस्तात्क्षरकर्ता/ Authorized
Signatory

Printed on 31/07/2023 by ID: 56187 Page no: 3

 TAX INVOICE

Invoice Serial No: 30602W3PE0000010 Invoice Date: 31/07/2023

Details of Supplier:
National Insurance Company Limited.,
HYDERABAD DIVISION II CSR Plaza,D No. 6-3-347/9/4,2nd Floor,Dwarakapuri ColonyPunjagutta,Hyderabad - 500082
State : 36 , Telangana
GSTIN No : 36AAACN9967E6ZZ

Details Of Receiver : ABS FUJITSU GENERAL PVT LTD

Address : H NO. 7-1-214/4, 2ND FLOOR, JANA ARCADE, DHARAM KARAN ROAD, MVR COLONY, AMEERPET, HYDERABAD
City : HYDERABAD,
District: HYDERABAD,
State: TELANGANA,
PIN: 500016.

Place Of Supply State : Telangana

State Code : 36
GSTIN No : 36AAFCA1594D1ZV

केरला बाढ़
सेवा का सीजीएसटी की राशि/ एसजीएसटी/यूटीजीएसटी/ उपकर/Kerala
आईजीएसटी/IGST
छूट/ टैक्स योग्य/
सैक कोड/ विवरण/ कुल/Total(
CGST SGST/UTGST
Flood Cess
Descripti Discou मूल्य/Taxable
SAC Code `)
on of nt Value(`)
Service राशि/ राशि राशि/ राशि/Amount(
दर/Rate Amount( दर/Rate Amount( दर/Rate Amount( `)
`) `) `)
Other non-
life
insurance 0
997139 services 30,098 0% 30,098 9% 2,709 9% 2,709 0% 0
(excluding
reinsuranc
e services)
TOTAL 30,098 30,098 2,709 2,709 0 0
कुल इनवॉयस मूल्य (अंकों में )Total Invoice Value (In figures) :
` 35,517
कुल इनवॉयस मूल्य (शब्दों में)Total Invoice Value (In words) : रूपए/Rupees
Thirty Five Thousand Five Hundred Seventeen
केवल/Only.
रिवर्स चार्ज के अधीन टैक्स की राशि/ Amount of Tax Subject to Reverse Charge : No

E.&.O.E कृते नेशनल इन्श्योरेन्स कंपनी लिमिटेड/ For

and on behalf of National Insurance Company Limited

अधिकृत हस्तात्क्षरकर्ता/ Authorized Signatory

Printed on 31/07/2023 by ID: 56187 Page no: 4