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Servicing Office Address

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Puducherry - Ariyankuppam,First Floor, No 7, Veerampattinam Street,

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Ariyankuppam

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GSTIN No: 34AAACN9967E1Z8

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RECEIPT

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Customer Details Collection Details

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Name : Mr SIVAMANI S Agent Code : 9000194763

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Address : FIFTH STREET, V.S.NAGAR, MADUKARAI, Collection Number : 50602381220000000495

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PUDUCHERRY , TAMIL NADU , Collection Date : 31/01/2023
PUDUCHERRY Bank Account : 9172

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Pin Code : 605105

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Received with thanks from Sri/Smt Mr SIVAMANI S

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a sum of 1326 (RUPEES ONE THOUSAND THREE HUNDRED TWENTY SIX ONLY) by CD
towards 1 Year Package Policy Policy as per details given hereunder

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Sl Policy Number TR Code End/Ren/Dec/Clm End/Ren/Dec/Clm A/C Particulars A/C Head Credit Amount Debit Amount Amount
No. Year Number (General Ledger) Received

00
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1 50602331226260000301 11
62 C.D CONTROL A/C 5076 0.00 1326.00 -1326.00
22
2 50602331226260000301 11 CASH PREMIUM A/C 5083 1124.00 0.00 1124.00
31
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3 50602331226260000301 11 IGST_TN_Int_Liab 7387 202.00 0.00 202.00

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TOTAL : 1326.00 1326.00 0.00

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Particulars : CD
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For National Insurance Company Ltd.,

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1.Please quote collection no. and date in all correspondeces

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2.The stamp has been defaced and retained at the office against the issued
policy.
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3.We hereby declare that though our aggregate turnover in any preceding
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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
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Authorised Signatory
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in terms of the provisions of the said sub-rule.

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NIC/UBPORTAL/9000194763 31/01/2023 09:03 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
 Issuing Office Name & Address
PUDUCHERRY - ARIYANKUPPAM , FIRST FLOOR, NO 7,
VEERAMPATTINAM STREET, ARIYANKUPPAM
Tel: Fax:
GSTIN No: 34AAACN9967E1Z8

National Insurance Company Ltd.

Registered & Head Office: 3, MIDDLETON STREET, POST BOX NO. 9229, KOLKATA - 700 071
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
Form 51 of the Central Motor Vehicle Rules, 1989
Policy No: 50602331226260000301 2W 1 Year Package Policy from 21:03 Hrs of 31/01/2023 to Midnight of 30/01/2024 IXI
Insured Details

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Name : Mr SIVAMANI S

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Address : FIFTH STREET, V.S.NAGAR, MADUKARAI, PUDUCHERRY , TAMIL NADU , PUDUCHERRY

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Pincode : 605105 Telephone : 9994214820 Email : veltech0322@gmail.com

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PAN No. : GSTIN No. : Aadhar No. : xxxx xxxx 8916

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Channel : KANTHAVELU R Mobile : 9087244349 Email : kanthavelu1993@gmail.com

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Aadhar : PAN : xxxxxx641F Code. : 506023 / 9000194763

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Token No :20230131183636237463 Approver : VIJAYAKUMAR K(74376) Remarks : APPROVED

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Vehicle age>10 Years Approver : VIJAYAKUMAR K(74376)

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Vehicle Details

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Make & Model Two Wheeler Hero Splendor Plus Cast

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Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District

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PY-01-BP-5042 HA10EFBHMA5603 MBLHA10EZBHM75164 97 2012 1+1 PUDUCHERRY

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Geographical Area : INDIA.

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FastTag ID : .
Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV

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Rs.10,000 - - - - Rs.10,000

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OD Premium Breakup in Rs. :18
TP Premium Breakup in Rs.
Basic OD Premium 144.20 Basic TP Premium
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714.00
(+) Geographical Area Extension - (+) Geographical Area Extension -
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(-) Vol. Excess Discount - (+) WC for Driver -

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(-) Auto. Assoc Discount - (+) PA to owner driver YES 295.00

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(-) Anti-theft Discount - (+) PA to unnamed PAX -

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(-) Other Discount - (-) Discount For Limited TPPD -

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(-) NCB Discount 20% -28.84 TP Total (Rounded Off) 1,009.00

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(+) Nil Depreciation - OD Total (Rounded Off) 115.00

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(+) Nil Depreciation Plus - TOTAL PREMIUM 1,124.00

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(+) NCB Protect - GST 202.00

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(+) Engine Protect - NET PAYABLE 1,326.00

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(+) Invoice Protect - Collection Number :50602381220000000495 dated 31-Jan-2023

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(+) Loss of Driving Licence -

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OD Total (Rounded Off) 115.00 Subject to IMT Endorsement No. 22,24,25

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Excess : Compulsory: Rs. 100 Imposed: Rs.0 Voluntary: Rs. 0

Limitation 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
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making (e) Speed Testing and Reliability Trials (f) Use in connection with Motor Trade
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Drivers Clause : Any person including Insured Provided that a person driving holds an effective driving licence at the time of the accident and is not disqualified from holding or obtaining such a
licence. Provided also that the person holding an effective Learner's Licence may also drive the vehicle and such a person satisfies the requirements of Rule 3 of Central Motor
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Vehicles Rules, 1989.

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Limits of Liability Clause: Under section 1(i) Such amount as is necessary to meet the requirements of the motor vehicle act 1988.
Under section 1(ii) Damage to third party property is Upto Rs. 1,00,000 . PA Cover under section 3 for owner-driver is Rs. 15,00,000.
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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 reasons of wider terms
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appearing in the certificate in order to comply with the Motor Vehicles 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.
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Financier : SELF OWNED

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Prev Policy : The New India Assurance Company Ltd. (Pol No: 31030031210100334436 Expiry Date: 19/01/2023)
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Nominee Name : PAZHANIYAMMAL Relation : WIFE Age : 30 Years

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NOTE : Warranted that in case of dishonour of the premium cheque, this document stands automatically cancelled 'AB-INITIO'.
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Policy stamp to be defaced at the respective policy servicing office.

I/We hereby certify that this Certificate cum Schedule of Insurance is issued in accordance with the provisions of chapter X and chapter XI of Motor Vehicles Act,1988.
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Authorised Signatory
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For & On behalf of

National Insurance Company Limited
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NIC/UBPORTAL/9000194763 31/01/2023 09:03 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
Customer Care Toll Free Number: 1800 345 0330 Email: customer.support@nic.co.in