Servicing Office Address

Dewas Division,2, Tarani Colony, A.B Road, Dewas, Madhya Pradesh, Pin :
455001
GSTIN No: 23AAACN9967E1ZB

RECEIPT

Customer Details Collection Details

Name : Mr MR KEDAR SINGH YADAV Agent Code : 9000142088
Address : 8 KUNJ GALI BHOURASA TEH.SONKATCH , Collection Number : 32180081190000009373
MADHYA PRADESH , Collection Date : 10/02/2020
Pin Code : 455001 Bank Account : 9172

Received with thanks from Sri/Smt Mr MR KEDAR SINGH YADAV

a sum of 3859 (RUPEES THREE THOUSAND EIGHT HUNDRED FIFTY NINE ONLY) by CD
towards 1 Year Package Policy Policy as per details given hereunder

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

1 32180031196160006134 11 C.D CONTROL A/C 5076 0.00 3859.00 -3859.00

2 32180031196160006134 11 CASH PREMIUM A/C 5083 3271.00 0.00 3271.00

3 32180031196160006134 11 CGST_MP_Int_Liab 7361 294.00 0.00 294.00

4 32180031196160006134 11 SGST_MP_Int_Liab 7362 294.00 0.00 294.00

TOTAL : 3859.00 3859.00 0.00

Particulars : CD

For National Insurance Company Ltd.,

1.Please quote collection no. and date in all correspondeces
2.The stamp has been defaced and retained at the office against the issued
policy.

Authorised Signatory

NIC/UBPORTAL/9000142088 10/02/2020 03:28 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
 Issuing Office Name & Address
DEWAS DIVISION ,2, TARANI COLONY, A.B ROAD, DEWAS, MADHYA
PRADESH, PIN : 455001
Tel: Fax: 07272 250074 (G) , 253184
GSTIN No: 23AAACN9967E1ZB

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: 32180031196160006134 1 Year Package Policy from 00:00 Hrs of 12/02/2020 to Midnight of 11/02/2021 IXI
Insured Details
Name : Mr MR KEDAR SINGH YADAV
Address : 8 KUNJ GALI BHOURASA TEH.SONKATCH , MADHYA PRADESH ,
Pincode : 455001 Telephone : 9752266684 Email : khandelwal.shirish72@gmail.com
PAN No. : GSTIN No. : Aadhar No. :
Channel : SHIRISH KHANDELWAL Mobile : 9827253026 Email : khandelwal.shirish72@gmail.com
Aadhar : PAN : xxxxxx197K Code. : 321800 / 9000142088
Vehicle Details
Make & Model Private Car MARUTI SUZUKI ALTO LX BS-IV
Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District
MP-09-CG-1988 3782496 1558789 HATCHBACK 796 2010 1+4 INDORE
Geographical Area : INDIA.
Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV
Rs.81,000 - - - - Rs.81,000

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

Basic OD Premium 1,773.90 Basic TP Premium 2,072.00
(+) Electrical Access. Premium - (+) WC for Driver YES 50.00
(+) Bi-fuel kit Loading - (+) Wider Legal Liability to employees -
(+) Geographical Area Extension - (+) Geographical Area Extension -
(-) Vol. Excess Discount - (+) PA to owner driver YES 295.00
(-) Auto. Assoc Discount - (+) PA to unnamed PAX ( 4 No. x Rs. 50,000 ) YES 100.00
(-) Anti-theft Discount - (-) Discount For Limited TPPD -
(-) Other Discount - -266.09 (+) Bi-fuel kit Loading -
(-) NCB Discount 50% -753.91 TP Total (Rounded Off) 2,517.00
(+) Nil Depreciation - OD Total (Rounded Off) 754.00
(+) Nil Depreciation Plus - TOTAL PREMIUM 3,271.00
(+) NCB Protect - GST 588.00
(+) Engine Protect - NET PAYABLE 3,859.00
(+) Invoice Protect - Collection Number :32180081190000009373 dated 10-Feb-2020
OD Total (Rounded Off) 754.00 Subject to IMT Endorsement No. 16,24,25,28
Excess : Compulsory: Rs.1,000 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
making (e) Speed Testing and Reliability Trials (f) Use in connection with Motor Trade
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
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 . PA Cover under section 3 for owner-driver is Rs. 15,00,000.
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
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.
Financier : SELF OWNED
Prev Policy : National Insurance Company Limited (Pol No: 32180031186160001103 Expiry Date: 11/02/2020)
Nominee Name : MRS SANGEETA YADAV Relation : WIFE Age : 36 Years
NOTE : Warranted that in case of dishonour of the premium cheque, this document stands automatically cancelled 'AB-INITIO'.
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.

Authorised Signatory
For & On behalf of
National Insurance Company Limited

NIC/UBPORTAL/9000142088 10/02/2020 03:28 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