The Certificate of Insurance Page 1 of 2

ORIGINAL FOR RECIPIENT/DUPLICATE FOR SUPPLIER.

TAX INVOICE/CERTIFICATE CUM POLICY SCHEDULE
(FORM 51 OF THE CENTRAL MOTOR VEHICLES RULES, 1989)
Policy Type Stand-alone OD Policy ( Private Vehicle ) Proposal No. & Date SR13188028 / 27-Mar-2023
Policy No. & Type 20050031231849114044 Period of Insurance 08-Apr-2023 to 07-Apr-2024
Policy Issued On 27-Mar-2023 (00:00) Vehicle Identification No. MA3ERLF1S00A30862
Insured Name Mr S Sanjeev Singh Geographical Area INDIA
Invoice No 4131237373984 Accounting Code of Service 997134
S/O-MR.SOUGAIJAM KAMO SINGH,VILL-JIRIBAM MUNICIPAL COUNCIL WARD NO- 9, DIST- IMPHAL EAST MANIPUR,
Insured Address
IMPHAL-795116, Manipur
Insured State & Code Manipur-14 Place of Supply Manipur GSTIN of Customer GSTUNREGISTERED
INSURED MOTOR VEHICLE DETAILS INSURED DECLARED VALUE (IDV) (in Rs.)
Make Maruti Vehicle 394894
Model & Variant EECO BSVI 5 STR AC (O)/ Non Electrical Accessories 0
Registration No AS11X9755 Electrical Accessories 0
Year of Manufacture 2022 CNG/ LPG Kit 0
Engine- Chassis No G12BN 1079136 - MA3ERLF1S00A30862 Total IDV 394894
Cubic Capacity 1196
Seating Capacity 5
Type Of Body Saloon
RTO Location AS11X9755 / IMPHAL
Schedule Of Premium (Amount in Rs.)
OWN DAMAGE SECTION (A) Pre-Existing Third Party Policy Details.
Vehicle 3906 Insurance Company Name THE NEW INDIA ASSURANCE CO. LTD
Elec. Accessories 0 Policy No. 98000031220911423006
Risk Inception Date 08-Apr-2022
Non- Elec. Accessories 0
Risk Expiry Date 07-Apr-2025
Kit (IMT-25) 0
Extra Premium towards Inbuilt CNG/LPG NA MISP - JAIN UDYOG, SILCHAR
Basic Premium 3906
Geographical Area Extn. (IMT-1) NA Notes : ( For Stand-alone OD Policy )
Lamp, Tyres etc. (IMT 23) 0
1. Policy Issuance is the subject to the realisation of cheque.
Driving Tuition Loading On OD Premium (60%) NA 2. Consolidate stamp duty paid to State Exchequer
Fiber Glass Tank 0 3. The Policy is subject to a compulsory Deductible of Rs 1000 (IMT -22)
4. Voluntary excess Rs (0)
Sub-Total Additions 0 5. Subject to Endorsements IMT
Deductibles 6. The Coverage under this policy is only for Own Damage and no other liability in
connection with the vehicle.
Voluntary Deductibles (IMT 22A) 0 7. OD Premium rates are different for NCB/Non-NCB class of customer. In case of change from
Anti-Theft Device (IMT-10) 0 NCB to Non-NCB, the recoverable amount may be more than the NCB amount.
AAI Membership (IMT-8) 0
No Claim Bonus (20%) 781
Discount for vehicles designed for handicapped NA
Sub - Total Deductibles 781
Add - On Coverages
Nil Depreciation Plus 0
Engine Protect 0
Invoice Protect 0
Net own Damage Premium (A) 3125
IGST@18% 562.50
Total OD Premium 3688
Nominee Details : Nominee Name LAMABAM RANJITA DEVI Age 32 Relation Wife
Payment Method Cheque No./Transaction No. Bank Name Amount
Payment Detail
Credit Card 75451074039 ICICI BANK LIMITED 3688
Financier Type Not Financed Financier Name NA Financier Branch NA
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 : http://www.gbic.co.in/ombudsman.html
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 National 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:-Silchar Division, Capital Travels Building, Club Road , Silchar, Dist: Cachar, Assam
GSTIN: 18AAACN9967E1Z2, CIN No.:U10200WB1906GOI001713
State Name : Assam

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