Issuing Office Name & Address

MUMBAI DIRECT AGENTS BRANCH II, FIRST FLOOR, STERLING CINEMA

BUILDING, 65, MURZABAN STREET, FORT, MUMBAI, PIN : 400001
Tel NO: 18003450330 Email: coverfox.tieup@nic.co.in
GSTIN No: 27AAACN9967E1Z3

National Insurance Company Ltd.

Registered & Head Office: Premises No.18-0374, Plot No. CBD-81, New Town, Kolkata-700156
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
Form 51 of the Central Motor Vehicle Rules, 1989

Policy No: 26020131236710083949 1 Year Liability Only Policy Issued on 06-Jan-2024 16:25:32 Effective from 00:00 Hrs of 09-Jan-2024 to Midnight of 08-Jan-
2025
Insured Details
Name : Mr. Rakesh Raushan
Pincode : 784104 Telephone : 8120080709 Email : rraushan.me@gmail.com
PAN No. : APJPR6918L GSTIN No. : Aadhar No :

Channel : Coverfox Insurance Broking Pvt. Ltd Telephone : 02248971018 PAN : AAFCC2890J Email : help@coverfox.com Code : 260201 / 9104230000000
Vehicle Details
Make & Model Private Car HYUNDAI I10 SPORTZ 1.2 KAPPA 2
Reg. No. Engine. No. Chassis. No. Geographical Area CC Mfg. Year. Seat. Cap. Reg. Disrict.
AS03M0266 G4LACM891758 MALAN51CLCM229861G INDIA 1197 2012 5 Jorhat
Reg Date Non Elec Access Elec Access Bi-fuel kit Vehicle IDV Total IDV
05-Oct-2012 NA NA NA 0 Rs.0
OD Premium Breakup in Rs. TP Premium Breakup in Rs.
Basic Own Damage Premium NA Basic Third Party Liability 3416.0
(+) Elec. Accessories NA (+)WC for Driver
(+) Bi-fuel kit loading - (+) Wider Legal Liability To Employees -
(+) Geographical Area Extension - (+) Geographical Area Extension -
(-) Vol. Excess Discount - (+) PA to owner driver - NA
(+) CNG/LPG Kit (IMT - 25) - NA CNG/LPG kit - NA
(-) NCB Discount NA -
(+) Nil Depreciation Plus NA NA TP Total (Rounded off) 3416.0
(+) NCB Protect - NA OD Total (Rounded off) NA
(+) Non-Elec. Accessories NA TOTAL PREMIUM 3416.0
(+) Invoice Protect - NA GST 615.0
(+) Engine Protect - NA NET PAYABLE - 4031.0
OD Total (Rounded off) NA Collection Number : CFOX30919940 dated 06-Jan-2024
Subject to IMT Endorsement No. 16, 22A, 29
Excess : Compulsory: Rs.1000 Imposed: Rs.0 Voluntory: Rs.0

Use only for social, domestic and pleasure purposes and for the insured's business or profession. The Policy does not cover use for hire or reward, tuition, racing, pace
Limitation as to use : making,reliability trial, speed testing, carriage of goods(other than samples or personal luggage) in connection with any trade or business or use for any purpose in connection with
MotorTrade

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
Drivers Clause : alicense, 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
CentralMotor Vehicles Rules, 1989.

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. 7,50,000 .

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 the reason of wider
termsappearing 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
IMPORTANT NOTICE :
ANDRIGHT OF RECOVERY" No Claim Bonus will only be allowed, provided the policy is renewed within 90 days of the expiry of the previous policy. No Claim Bonus is subject to
noclaim on the previous policy. Benefits under the policy stands forfeited if claim is/was made in previous policy. For legal interpretation, the English version will hold good.

Financer Name: NA

Prev Policy : -( pol no. 20090031226760003800 Expiry Date: 08-Jan-2024 )

Nominee Name : NA Relation : NA Age : NA Years

Transaction Date: 06-Jan-2024 Transaction Number : ZHMP1658843418 Inspection ID : :
Disclaimer: It is warranted that IN CASE OF DISHONOUR OF THE PREMIUM CHEQUE, THIS DOCUMENT STANDS AUTOMATICALLY CANCELLED 'AB-INITIO'.
In the event of misrepresentation, fraud or non-disclosure of material fact, the Company reserves the right to cancel the Policy. The policy is issued based on the information provided by you, which is availablewith the company. In case of discrepancy/non
recording of relevant information in the policy, the insured is requested to bring the same to the notice of the company within 15 days. This Policy is to be read inconjunction with the Policy wordings available on the website https://nationalinsurance.nic.co.in
of the Company. On renewal, the benefits provided under the policy and/or terms and conditions of the policyincluding premium rate may be subject to change.

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.

Signatory For & On behalf of

National Insurance Company Limited