11/25/23, 5:42 PM MARUTI

ORIGINAL FOR RECIPIENT / DUPLICATE FOR SUPPLIER

TAX INVOICE/ENDORSEMENT CERTIFICATE

"Fourth Floor, Parsavnath Capital Tower , Bhai Veer Singh Marg,

New Delhi New Delhi 110001",
IRDA Reg No. 58,CIN No:L67200MH2000PLC129408
GSTN:07AAACI7904G1ZP

Endorsement Schedule
Endorsement No. ED00000000355429 Endorsement Date & Time 25-NOV-2023 16:01:01
Policy No 3001/MI-11498257/00/000 Policy Type Annual Package Policy
Risk Inception Date 28-NOV-2022 Policy Expiry Date 27-NOV-2023
Insured Name G BALA BHASKARA REDDY Insured State Name & Code Andhra Pradesh-19
Insured Address S/O G.BALA NARAYANA REDDY,FLAT NO:36, ..
Invoice Number 181022411013E01
VIJAYA HOMES,PULIVENDULA 516390
Accounting Code of Service 997134 Place of Supply Andhra Pradesh
GSTIN of Customer UNREGISTERED Type of Endorsement Premium
Endorsement Category Ownership Transfer Total Endorsement Charges 110
Part A Premium 43 Part B Premium 0
Endorsement Charges(Taxable Value) 93 IGST (0%) 0

At the request of the insured, it is hereby declared and agreed that the following items under the withstanding policy has been changed / altered.
Not withstanding anything herein to the contrary contained, at the request of the insured, it is hereby declared and agreed that under the within mentioned policy And not as stated
therein.

Endorsement Details (Premium)

Endorsement Field Old Value New Value
Customer Type INDIVIDUAL INDIVIDUAL
Prefix Mr. Mrs.
First Name G BALA O
Middle Name .
Last Name BHASKARA REDDY VENGAMMA
Address1 S/O G.BALA NARAYANA REDDY,FLAT NO:36, W/O O OBULA REDDY 4-9-11 SREE RAMA HALL RAOD
Address2 .. PULIVENDULA YSR KADAPA
Landmark AP
Pincode 516390 516390
Locality VIJAYA HOMES,PULIVENDULA Pulivendla
City CUDDAPAH Kadapa
State Andhra Pradesh Andhra Pradesh
Primary Mobile No 9440996086 9492721808
Secondary Mobile No. 9000616299
Email Id balabhaskarreddy@rediffmail.com
Gender MALE Female
PAN AMFPV6718D
Date Of Birth 06-JUN-1974 01-JUL-1957
Financier Details finance Non-Finance
Nominee Name S SMITHA O OBULA REDDY
Nominee Age 40 68
Nominee Relation Wife Husband
Subject to fullfillment of conditions. if any.mentioned in remarks.

I/We hereby certify that the policy to which this certificate relates as well as this certificate of insurance are issued in accordance with the provisions of chapter X and chapter X! of
M.V. act, 1988.
Dealer Remarks: REQUEST FOR NAME CHANGE
IC Remarks: transfer and ncb

For ICICI LOMBARD GENERAL INSURANCE CO LTD

We hereby declare that though our aggregate turnover in any
preceding financial year from 2017-18 onwards is more than
the aggregate turnover notified under sub-rule (4) of rule 48,
we are not required to prepare an invoice in terms of the
provisions of the said sub-rule.
Authority Signature

Note: This is a Transfer Case

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