The Certificate of Insurance Page 1 of 2

ORIGINAL FOR RECIPIENT/DUPLICATE FOR SUPPLIER.

TAX INVOICE/CERTIFICATE CUM POLICY SCHEDULE B

(FORM 51 OF THE CENTRAL MOTOR VEHICLES RULES, 1989)
Policy Type Stand-alone OD Policy ( Private Vehicle ) Proposal No. & Date SR16371367 / 22-Dec-2023
Policy No. & Type 902035369/SR16371367 Period of Insurance 22-Dec-2023 to 21-Dec-2024
Policy Issued On 22-Dec-2023 (00:00) Vehicle Identification No. MA3EUA61S00J82648
Insured Name Mrs Kalpana Barman Geographical Area INDIA
Invoice No 69/SR16371367 Accounting Code of Service 997134
W/O- LATE. JIBAN RAM BARMAN, DHAMPUR, LAKHIPUR, DIST- CACHAR,ASSAM,,
Insured Address
SILCHAR-788104, Assam
Insured State & Code Assam-18 Place of Supply Assam GSTIN of Customer GSTUNREGISTERED
INSURED MOTOR VEHICLE DETAILS INSURED DECLARED VALUE (IDV) (in Rs.)
Make Maruti Vehicle 288714
Model & Variant NEW ALTO VXI/MARUTI ALTO VXI 0.8L 5MT Non Electrical Accessories 0
Registration No AS11W2392 Electrical Accessories 0
Year of Manufacture 2021 CNG/ LPG Kit 0
Engine- Chassis No F8DN 6625229 - MA3EUA61S00J82648 Total IDV 288714
Cubic Capacity 796
Seating Capacity 5
Type Of Body Saloon
RTO Location AS11W2392 / SILCHAR
Schedule Of Premium (Amount in Rs.)
OWN DAMAGE SECTION (A) Pre-Existing Third Party Policy Details.
Vehicle 1317 Insurance Company Name Universal Sompo General Insurance Co. Ltd
Elec. Accessories 0 Policy No. 2367/65180427/00/000
Risk Inception Date 22-Dec-2021
Non- Elec. Accessories 0
Risk Expiry Date 21-Dec-2024
Kit (IMT-25) 0
Extra Premium towards Inbuilt CNG/LPG NA MISP - JAIN UDYOG, SILCHAR
Basic Premium 1317
Geographical Area Extn. (IMT-1) NA
Notes : ( For Stand-alone OD Policy )
Lamp, Tyres etc. (IMT 23) 0
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
3. The Policy is subject to a compulsory Deductible of Rs 1000 (IMT -22)
Sub-Total Additions 0 4. Voluntary excess Rs (0)
Deductibles 5. Subject to Endorsements IMT ,7 10,
Voluntary Deductibles (IMT 22A) 0 6. The Coverage under this policy is only for Own Damage and no other liability in
connection with the vehicle.
Anti-Theft Device (IMT-10) 33 7. Warranted that the Insured named herein/owner of the vehicle holds a valid Pollution Under
AAI Membership (IMT-8) 0 Control (PUC) Certificate and/or valid fitness certificate, as applicable on the date of
commencement of the Policy and undertake to renew and maintain a valid and effective PUC
No Claim Bonus (25%) 321
and/or fitness certificate as applicable during the subsistence of the Policy
Discount for vehicles designed for handicapped NA 8. OD Premium rates are different for NCB/Non-NCB class of customer. In case of change from
Sub - Total Deductibles 354 NCB to Non-NCB, the recoverable amount may be more than the NCB amount.
Add - On Coverages
DEPRECIATION REIMBURSEMENT 0
Engine Guard 0
Return To Invoice 0
Net own Damage Premium (A) 963
CGST@9% 86.67
SGST@9% 86.67
Total OD Premium 1136
Nominee Details : Nominee Name AMARJIT BARMAN Age 31 Relation Son
Payment Method Cheque No./Transaction No. Bank Name Amount
Payment Detail
Credit Card 77014916833 ICICI BANK LIMITED 1136
Financier Type Financed Financier Name STATE BANK OF INDIA Financier Branch SILCHAR 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 SBI General Insurance Company Ltd.

Authorized Signatory
Policy Issuing Office:-2nd Floor,Lakshmi Darshan Building,Ulubari, (opposite Bora Service)G.S. Road ,Guwahati ¿ 781007
GSTIN: 18AAMCS8857L1ZB, CIN No.:U66000MH2009PLC190546
State Name : Assam

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