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Servicing Office Address

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Samastipur Business Office,2nd Floor, Jagannath ComplexMohanpur Road,

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Near Chandana Petrol PumpSamastipurSamastipur

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GSTIN No: 10AAACN9967E3ZG

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RECEIPT

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Customer Details Collection Details

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Name : Mr MD ASGAR ALI Agent Code : 9800008031
Address : S/O-MD GULZAR MAIN WARD NO-07 Collection Number : 17120081248000005646

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PARTAPUR SAMASTIPUR , BIHAR , Collection Date : 09/07/2024

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Pin Code : 848102 Bank Account : 9173

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Received with thanks from Sri/Smt Mr MD ASGAR ALI

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a sum of 7457 (RUPEES SEVEN THOUSAND FOUR HUNDRED FIFTY SEVEN ONLY) by CD

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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

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No. Year Number (General Ledger) Received

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1 17120031246160002823 11 C.D CONTROL A/C 5076 0.00 7457.00 -7457.00

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2 17120031246160002823 11 CASH PREMIUM A/C 5083 6319.00 0.00 6319.00

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3 17120031246160002823 11 CGST_BR_Int_Liab
00 7313 569.00 0.00 569.00
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4 17120031246160002823 11 SGST_BR_Int_Liab 7314 569.00 0.00 569.00

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TOTAL : 7457.00 7457.00 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

2.The stamp has been defaced and retained at the office against the issued
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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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in terms of the provisions of the said sub-rule.

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NIC/UBPORTAL/9800008031 09/07/2024 08:43 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
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 Issuing Office Name & Address
SAMASTIPUR BUSINESS OFFICE ,2ND FLOOR, JAGANNATH COMPLEXMOHANPUR
ROAD, NEAR CHANDANA PETROL PUMPSAMASTIPURSAMASTIPUR
Tel: Fax: 222659 (G) , 227339
GSTIN No: 10AAACN9967E3ZG
RSA Service Provider: M/s ki MOBILITY SOLUTIONS PRIVATE LIMITED
RSA Service Provider Toll Free Number :- 1800 570 1906
For feedback to RSA:- Email: rsa.service@tvs.in

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 as amended from time to time
Policy No: 17120031246160002823 Private Car 1 Year Package from 00:00 Hrs of 10/07/2024 to Midnight of 09/07/2025 IXI
Policy
Insured Details
Name : Mr MD ASGAR ALI
Address : S/O-MD GULZAR MAIN WARD NO-07 PARTAPUR SAMASTIPUR , BIHAR ,
Pincode : 848102 Telephone : 7783870125 Email : npcmpur2021@gmail.com
PAN No. : GSTIN No. : Aadhar No. : xxxx xxxx 4518
Channel : ANITA DEVI Mobile : 9471644203 Email : anilksinghmpur@gmail.com
Aadhar : PAN : xxxxxx063R Code. : 171200 / 9800008031
Vehicle Details
Make & Model Private Car HYUNDAI ELITE I20 ASTA 1.2
Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District

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BR-01-BV-6800 G4LADM033959 MALBB51BLDM548985D HATCHBACK 1197 2013 1+4 PATNA

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Geographical Area : INDIA.

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FastTag ID : 0.

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

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Rs.2,06,856 - - - - Rs.2,06,856

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OD Premium Breakup in Rs. TP Premium Breakup in Rs.

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Basic OD Premium 7,095.16 Basic TP Premium 3,416.00

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(+) Electrical Access. Premium - (+) WC for Driver YES 50.00

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(+) Bi-fuel kit Loading - (+) Wider Legal Liability to employees -

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(+) Geographical Area Extension - (+) Geographical Area Extension ul- -
(-) Vol. Excess Discount - (+) PA to owner driver -
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(-) Auto. Assoc Discount - (+) PA to unnamed PAX -

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(-) Anti-theft Discount - (-) Discount For Limited TPPD -

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(-) Other Discount - -3,547.58 (+) Bi-fuel kit Loading -

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(-) NCB Discount 20% -709.52 TP Total (Rounded Off) 3,466.00

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(+) Nil Depreciation - OD Total (Rounded Off) 2,853.00

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(+) Nil Depreciation Plus - TOTAL PREMIUM 6,319.00

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(+) NCB Protect - GST 1,138.00

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(+) Engine Protect - NET PAYABLE 7,457.00

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(+) Invoice Protect - Collection Number :17120081248000005646 dated 09-Jul-2024

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(+) Consumables Protect - Subject to IMT Endorsement No. 24,25,28

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(+) RSA Protect YES 15.00

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OD Total (Rounded Off) 2,853.00

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Excess : Compulsory: Rs.1,000 Imposed: Rs.0 Voluntary: Rs.0

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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
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
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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
Vehicles Rules, 1989 as amended from time to time.
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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 as amended from time to time.
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Under section 1(ii) Damage to third party property is Upto Rs. 7,50,000 .
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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 as amended from time to time is recoverable from the insured .See the clause headed
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"AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY". For legal interpretation, English version will hold good.
UIN : IRDAN058RP0034V01100001
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Financier : SELF OWNED

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Prev Policy : National Insurance Company Limited (Pol No: 17120031236160002855 Expiry Date: 09/07/2024)
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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.

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TP Rate Revision Notice: For all policies having an effective date on or after 1st April 2023, the TP premium is subject to revision as may be notified by the IRDAI.
The Insured should contact and submit the difference of premium to the policy issuing office on issuance of such notification by IRDAI.
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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 as amended from time to time.
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Policy Details Cashless Garages Details

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Authorised Signatory
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For & On behalf of

National Insurance Company Limited
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NIC/UBPORTAL/9800008031 09/07/2024 08:43 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