ORIGINAL FOR RECIPIENT/DUPLICATE FOR SUPPLIER.

TAX INVOICE/CERTIFICATE CUM POLICY SCHEDULE

(FORM 51 OF THE CENTRALMOTOR VEHICLES RULES, 1989)
Policy Type Stand-alone OD Policy ( Private Vehicle ) Proposal No. & Date SR16413591 / 25-Dec-2023
Policy No. & Type 2302205976188300000 Period of Insurance 26-Dec-2023 to 25-Dec-2024
Policy Issued On 25-Dec-2023 (00:00) Vehicle Identification No. MA3RYHL1SNM177626
Insured Name Mr. Bakshi Ram Saini Geographical Area INDIA
Invoice No 2059761883000 Accounting Code of Service 997134
Insured Address H.NO 126/9 SHIVPURI GURGAON other ,
GURGAON-122006, Haryana
Insured State & Code Haryana-06 Place of Supply Haryana GSTIN of Customer GSTUNREGISTERED
INSURED MOTOR VEHICLE DETAILS INSURED DECLARED VALUE (IDV) (in Rs.)
Make Maruti Vehicle 869200
Model & Variant NEW BREZZAK15C ISG 5MT ZXI BS6/NEW BREZZAK15C ISG 5MT ZXI BS6 VZR4AZA00 Non Electrical Accessories 0
Registration No HR26EZ6110 Electrical Accessories 0
Year of Manufacture 2022 CNG/ LPG Kit 0
Engine- Chassis No 7073644 - MA3RYHL1SNM177626 Total IDV 869200
Cubic Capacity 1462
Seating Capacity 5
Type Of Body Saloon
RTO Location HR26EZ6110 / GURGAON
Schedule Of Premium (Amount in Rs.)
OWN DAMAGE SECTION (A) Pre-Existing Third Party Policy Details.
Vehicle 4711 Insurance Company Name IFFCO TOKIO GENERAL INSURANCE COMPANY LIMITED
Elec. Accessories 0 Policy No. 13191175
Non- Elec. Accessories 0 Risk Inception Date 26-Dec-2022
Kit (IMT-25) 0 Risk Expiry Date 25-Dec-2025
Extra Premium towards Inbuilt CNG/LPG NA
Basic Premium 4711 MISP - PASCO AUTOMOBILES, GURGAON
Geographical Area Extn. (IMT-1) NA
Lamp, Tyres etc. (IMT 23) 0 Notes : ( For Stand-alone OD Policy )
Driving Tuition Loading On OD Premium (60%) NA
1. Policy Issuance is the subject to the realisation of cheque.
Fiber Glass Tank 0 2. Consolidate stamp duty paid to State Exchequer
Sub-Total Additions 0 3. The Policy is subject to a compulsory Deductible of Rs 1000 (IMT -22)
Deductibles 4. Voluntary excess Rs (0)
Voluntary Deductibles (IMT 22A) 0 5. Subject to Endorsements IMT 10,
6. The Coverage under this policy is only for Own Damage and no other liability in connection with
Anti-Theft Device (IMT-10) 118 the vehicle.
AAI Membership (IMT-8) 0 7. I / We hereby certify that the policy to which the certificate relates as well as the certificate of insurance
No Claim Bonus (20%) 919 are issued in accordance with the provision of chapter X, XI of M. V.Act 1988." The stamp duty of Rs
Discount for vehicles designed for handicapped NA 0.50 paid by Demand Draft, vide Receipt/Challan no. NO.LOA/CSD/547/2022/(Validity Period Dt.
23/12/2022 to Dt. 31/12/2023)/5450/22 DATE- 22/Dec/2022 as prescribed in Government of
Sub - Total Deductibles 1037 Maharashtra Order No. Mudrank 2017/CR.97/M-1, dated the 09th January 2018"
Add - On Coverages 8. OD Premium rates are different for NCB/Non-NCB class of customer. In case of change from NCB to
ZERO DEPRECIATION 0 Non-NCB, the recoverable amount may be more than the NCB amount.
Engine & Gear Box Protector 0
Return To Invoice 0
Net own Damage Premium (A) 3674
CGST@9% 330.66
SGST@9% 330.66
Total OD Premium 4335
Nominee Details : Nominee Name REKHASAINI Age 47 Relation Wife
Payment Method Cheque No./Transaction No. Bank Name Amount
Payment Detail
Electronic Payment 113121810717 ELECTRONIC PAYMENT 4335
Financier Type Financier Name Financier Branch
Limitations 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, f) Reliability Trials, g) Any purpose in connection with Motor Trade.
Driver: Any person including the insured, Provided that a person driving holds an effective driving license at the time of the accident and is not disqualified from holding or obtaining such a license; Provided also that the
person holding an effective learner's license may also drive the vehicle and that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
Deductibles: Deductible under section-I : Rs 1000(Compulsory Deductible Rs 1000 Imposed Deductible Rs. 0 and Voluntary Deductible Rs 0)
No Claim Bonus: The insured is entitled for a No Claim Bonus (NCB) on the Own Damage section of the policy, if no claim is made or pending during the preceding year (s), as per the following: The preceding year/20%,
Preceding Two consecutive years/25%, Preceding Three consecutive years/35%, Preceding Four consecutive years/45%, Preceding Five consecutive years/50%. No Claim Bonus will only be allowed provided the policy
is renewed within 90 days of the expiry date of the previous policy.
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 reason of wider terms appearing in the
Certificate in order to comply with the Motor Vehicle 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.
For information on ombudsman you may visit website : https://www.cioins.co.in/Ombudsman
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 XI of M.V. Act, 1988.
For HDFC ERGO General Insurance Company Limited
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.
Authorized Signatory
Policy Issuing Office:-SCO 237, 2nd floor, Sector -12, Karnal (Formerly HDFC General Insurance Limited from September 14, 2016 and L&T General Insurance Company Limited up to September 13, 2016)
GSTIN: 06AABCL5045N1ZC, CIN No.:U66030MH2007PLC177117
State Name : Haryana