पृष्ठांकन /Endorsement- Motor - Two Wheelers-Liability Only

Policy Number : जारीकर्ता कार्यालय/Issuing Office

36140031186700360139 कार्यालय कोड /Office Code : 361400
कार्यालय पता / Office Address : GURGAON
DIVISION I SCO 41-43, Sector 31/32 A,
व्यवसाय स्त्रोत/ Business Source : Gurgaon, Gurgaon, Haryana - 122001.
87000100000001 State Code: 6 , Haryana
GSTIN: 06AAACN9967E2Z6
eMail:
विक्रय चैनल का नाम/ Sales Channel Name :
विक्रय चैनल संपर्क नम्बर/ Sales Channel
POLICY BAZAAR INSURANCE WEB
Contact Number : 9205584045
AGGREGATOR PVT LTD - HO

ग्राहक का नाम/Customer Name: MR ग्राहक आईडी/ Customer ID: 9549417339 पैन/ PAN:
AVIJIT CHAKRABORTY
पता/ Address: 21 PARUI KANCHA ROAD PARNASREE, City: फोन/ Phone:
KOLKATA, District: KOLKATA, State: WEST BENGAL, PIN:
700061. ई-मेल/ E-Mail:
Mobile: 8697672516

Policy Effective from 00:00 hours, on 19/03/2019 to midnight of 18/03/2020

Premium: ` 985.00 Total IDV: NA
CGST ` 0.00
19060636140010005179 Dt.
SGST/UTGST ` 0.00 Proposal Number and Date:
06/06/2019
IGST ` 177.00
Recoverable Stamp Duty: ` 0.00 Receipt Number: 361400811900000494690000000001
Total Amount: ` 1,162.00 Receipt Date: 06/06/2019, 00:00
(Rupees One Thousand One Hundred Sixty Two
Co-Insurance Details: N/A
Only.)

Endorsement Effective from 10:24 hours,on 29/04/2019 to midnight of 18/03/2020

Additional Premium: ` 0.00 Insured's Request Date: 05/07/2019
CGST ` 0.00
SGST/UTGST ` 0.00 Endorsement Number: 361400311882103498
IGST ` 9.00
Recoverable Stamp Duty: ` 0.00 Endorsement Issue Date: 05/07/2019
Total Amount*: ` 60.00 Receipt Number: 361400811810006478
(Rupees Sixty Only.) Receipt Date: 24/12/2018
* Transfer Fee: ` 50.00

General / Common Information change

It is hereby declared and agreed that with effect from 29/04/2019

In consequence of which, an additional premium of 60 is hereby charged to the Insured.

It is hereby understood and agreed that as from 29-APR-19 the interest in the policy is transferred to and vested in
Customer ID: 9549417339 Customer Name: AVIJIT CHAKRABORTY
who shall be deemed to be the insured and whose proposal and declaration shall be deemed to be incorporated in and to be the basis of
this contract.

IN CASE OF DISHONOUR OF THE PREMIUM CHEQUE, THIS DOCUMENT STANDS AUTOMATICALLY CANCELLED 'AB-INITIO'

For and On Behalf Of National Insurance Company Limited

Authorized Signatory

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पृष्ठांकन /Endorsement- Motor - Two Wheelers-Liability Only
Policy Number : जारीकर्ता कार्यालय/Issuing Office
36140031186700360139 कार्यालय कोड /Office Code : 361400
कार्यालय पता / Office Address : GURGAON
DIVISION I SCO 41-43, Sector 31/32 A,
व्यवसाय स्त्रोत/ Business Source : Gurgaon, Gurgaon, Haryana - 122001.
87000100000001 State Code: 6 , Haryana
GSTIN: 06AAACN9967E2Z6
eMail:
विक्रय चैनल का नाम/ Sales Channel Name :
विक्रय चैनल संपर्क नम्बर/ Sales Channel
POLICY BAZAAR INSURANCE WEB
Contact Number : 9205584045
AGGREGATOR PVT LTD - HO
ANNEXURE I– List of Applicable Clauses
The Following Clauses Included while Endorsement
• IMT 22

कृते नेशनल इन्श्योरेन्स कंपनी लिमिटेड/

For and on behalf of National
Insurance Company Limited

अधिकृत हस्तात्क्षरकर्ता/ Authorized Signatory

Printed on 05/07/2019 by ID: 73116 Page no: 2

 पृष्ठांकन /Endorsement- Motor - Two Wheelers-Liability Only
Policy Number : जारीकर्ता कार्यालय/Issuing Office
36140031186700360139 कार्यालय कोड /Office Code : 361400
कार्यालय पता / Office Address : GURGAON
DIVISION I SCO 41-43, Sector 31/32 A,
व्यवसाय स्त्रोत/ Business Source : Gurgaon, Gurgaon, Haryana - 122001.
87000100000001 State Code: 6 , Haryana
GSTIN: 06AAACN9967E2Z6
eMail:
विक्रय चैनल का नाम/ Sales Channel Name :
विक्रय चैनल संपर्क नम्बर/ Sales Channel
POLICY BAZAAR INSURANCE WEB
Contact Number : 9205584045
AGGREGATOR PVT LTD - HO
CERTIFICATE OF INSURANCE

Form 51 of the Central Motor Vehicle Rules, 1989

Certificate No.: 36140031186700360139 IYI

Particulars of vehicle insured

Reg. Mark, No.
Engine No. & Make, Model Year of Seating
& Place of Type of Body C.C Premium(`)
Chassis No & Variant Manufacture capacity
Registration
Others,
WB-01-AB- U3S5C0DB22730
Motor Cycle -
6644/ 6
Others & MCY 2013 others 346 2 ` 985.00
Kolkata - WB ME3U3S5C0DB2
- Others Non
01 27306
Electrical.

Name of Registration Authority Kolkata - WB 01

MR AVIJIT CHAKRABORTY,21 PARUI KANCHA ROAD
Name & Address of Insured
PARNASREE,KOLKATA,KOLKATA,WEST BENGAL,700061.
Geographical Area India
Business or Profession 5007
Effective date of commencement of Insurance for the purpose of Act. From 10:24 O' Clock on 29/04/2019.
Date of expiry of the insurance Midnight on : 18/03/2020

PERSONS OR CLASS OF PERSONS ENTITLED TO DRIVE

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.

LIMITATIONS AS TO USE
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 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 Motor Trade.

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.
Full address of Issuing Office: GURGAON DIVISION I SCO 41-43, Sector 31/32 For and on behalf of
A, Gurgaon, Gurgaon, Haryana - 122001 National Insurance Company Limited

Date of issue: 06/06/2019 Duly Constituted Attorney(s)

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 Debit Note

Details of Supplier:
National Insurance Company Limited.,
GURGAON DIVISION I SCO 41-43, Sector 31/32 A, Gurgaon, Gurgaon, Haryana - 122001
State : 6 , Haryana
GSTIN No : 06AAACN9967E2Z6

Details Of Receiver : MR AVIJIT CHAKRABORTY Invoice Serial No: 30936A9E00103498

Address: Invoice Date: 05/07/2019
21 PARUI KANCHA ROAD PARNASREE,
WEST BENGAL, Reference to Serial No. of Corresponding
700061. Tax Invoice / Bill of Supply
Reference to Date of the corresponding
Place of Supply State: West Bengal tax invoice / bill of supply
State Code : 19
GSTIN No: NA

SAC Description of Discou Taxable CGST SGST/UTGST IGST

Total(`)
Code Service nt Value(`) Rate Amount(`) Rate Amount(`) Rate Amount(`)
Motor vehicle
997134 0.00 0% 0.00 0% 0 0% 0 0% 9
insurance services
TOTAL 0.00 0.00 0 0 9
Total Value (In figures) : ` 60
Total Value (In words) : Rupees Sixty Only.
Amount of Tax Subject to Reverse Charge : No

E.&.O.E कृते नेशनल इन्श्योरेन्स कंपनी लिमिटेड/ For

and on behalf of National Insurance Company Limited

अधिकृत हस्तात्क्षरकर्ता/ Authorized Signatory

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