1 his DOGument is Digitall y Sig ned

tJ Lo~owd' ~~~tl0~ t1o~~ D~~~

THE ORIENTALINSU ANY LIMITED
( ~d<i $oFd~ :"'OQ W(:)~ )
(A Govt. ~hileliaAJnde
""i:lJiroeef & o~~~ 5~/O: 'LOoJ;o\J(f ~-::1' sl' lST
.!J, ~, ~o, 7037 , ~- l5/27, (;~<1
Corporat~~~RQ«; ~~A
P,B, N o.7ro1<j1a26mgA~ IDelhi·110 002

Pc:icy N',. : 422200/48/2021/2495 Prev oPolicy No ,

Cuver Note No, Cover Note Date

In:;ured's Code : 104406648 Issue Office code : 422200

Insured 's Name ' PLANT- TECH INDUSTRIAL Issue Office Name : DO MANGALORE (GSTI N:
SERVICES LTD , (GSTI N: 29AP,/\CT0627R4ZS)
29AABCP9785B1Z2)

Address : PLOT ~,:O , 245, KIADB INDUSTRi.'\L Address , Bf= fIlJTY PLAZA
ARE}\, BAiKAMPI\DY,MANG.t;LURU BALMJ\TT A ROAD
DAKSHIN KANNADA- 575 011
M/\NGALORE KARNATAKA 575001

Tei/Fax/Email 1 ( 0 1 NA TeUr-ax/E mail : 082 4-24 21325 /2421326/24279r ' i 0324-2442456

1 k,usha@criental insurClnce ,co ,in

' Dev.Oft.Code : NZ0000000225 AGENCY MANAGER D.O. MANGALORE

Agent/Broker : BB0000001070 SUJATHA SHETTY

Address :NEAR ULLAL RAILWAY STATION, KOTEKJiiR POS-,- ,SOMESHW/IR, MAN GALORE-
575022 ,MANGALORE, KARNATAKA,575001
,,
Tel/Fax/Email _____---1

Period of Insurance

Collection No . & Dt.

Gross Premium TotClI . 47,700

CO -insurance Details

Laws

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I
Place MANGI\LORE a:
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and or. of , ~ehaif
Date : 01/01/2021 [;J, ,Y·.. 'RDA·Hc"NO·55c ./'.,-";';-i\.,. I ~ ' : J~I :;;'llal Ins,mmce L,ompail'y' Llillited
,:Z' ~~ !~ ~~,
ThiS IS all electronically generdted document (POliCY S(;iI~dule),The /t~ ,~\ ~ ,,----
Policy documeni duly stamped wi:1 be seni by post. fi!J! · ~, o~
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I )
* ~ *1 \ ~~~
In case of any query rega rdin g the Policy please ca ii i oi! % MAN GAl URU e; v .; ~ --------:
Free No . 1800 11 8435 and 011 33 2084 85 , \~~ ' 75 001 ~'f :' :.J th o:iseli ~ry J

~ " ,!

CIN. U66010DL 1947GOIOOl'158 All the ,l\ mounts merllioneci in th is pOj.C~

+~(3k > , ' '''-i :~,\~~~~e P<l(Js , " t ;;
iilS~~AHn. (.~/,. .. " ' . '
:RDA Regn , No , 555 - Now YeL' can buy i! nd rel1 8W selecte ",G;,l;:;t:':,: ::; ;~ii "f: '-l~ '~:\Nw , o qen!il :; r. s "r1.in ce,m(] ,: r.

website : www.orientali nsurance.org.in, Toll Free No,: 1800 II 8485, CIN No.:U660 I DOL I 947GOI007 I 58
422200 I West Coast /80gsm ·08 I 2020/ RTC
 This Docu n.. nt is Digitally Signed

Signer: ATUL f£J2fj

R" . H
Date : Fri. Jan 1. 2" 4:4 . 7 1ST
Location : NOIDA
Attached to and forming part of policy number 422200/43/2021/2495 Rea son : Signing ~ , _ ICL

Details of Employees with Monthly W".!1es Abov",'rts.15CCC/·

I ~·..
~ Est. Cant Occupation Es hm Il ted Value of Estimated Table Place of
iNo . No. of ract totals a lary food/q rtrsl Total Employment
Emps Emps Iwage slother other earnings

I carnin gs considerations

1 1 Petrochemical Industry 120,000 120,000 A 1 Project manager

at HPCL Mittal
nrgy Ltd. Village
Ph ulokhari ,
Talwadi saboo
bthinda Punjab

Details of Employees with Monthly Wages Above RS.1 5000/·

-1--

rir . \ Est. Cont

I No . No. of ract
Occupation Estimated
~otalsalary
Value of
food/qrtrsl
Estimated
. Total
I I
Table Place of
IEmplo,moo'
I
I_J:
Emps Emps Iwageslother other earnings
Iearnings ,considerations
I

1 14 Petrochem ical Industry 31 .000 31,000 A 14 Project

engineer atHPC L
Millal nrgy Ltd .
Village Phulokhari ,
Talwadi saboo
bthinda Punjab

Details of Employees with Monthly Wages Ab:>ve RS.15000/·

- - . _ - ------ ---.--- - - - , - - - - I
I 1
I Sr. Est. . Co nt loccupation ~st: i7.· ·· Icd ;Vaiue of Estimated I Table Place of
I No . 1No. of In:
=t totalsalary food/qrtrsl Total i Employment
!
! Emps 'I E:'!'!. ps I i
Iwag.es/other other earnings
earnings considerations I
I I
L_..l.. ____ -1- I I
1 10 Petrochemical Industry 30,000 30 ,000 A 10 Safety officers
atHPCL Mittal nrgy
Ltd . Village
Phulokhari ,
Talwadi saboo
bth inda Punjab

1IIIIIIIIIUIIII!III~II~IIIII ~l l llllllllllil lllllllllllIII~IIII

Place : MANGALORE
For and On behalf of
Date : 01/01/2021 IRDA·REGNQ·556 The Oriental Insurance Company Limited

This is an electronically generated document (Policy ')chedule).The

q\ ~
Policy document duly stamped will be sent by post.

In case of any query regarding the Policy please c211 Tol!

Free No. 1800 11 8485 and 011 33208485 Authorised Signatory .,

CIN : U66010DL 1947GOI007158 All the Amounts rY'cntioned in this policy are in Indian Rupee Page 2 of 5
IRDA Regn. No. 556· Now you Cfln buy and renew selected policies online at WWvv.orientalinsurance .org .in
 Th is Document is Digitally Signed

Attached to and ro~ming part of policy number 422200/48/2021/2495

-----------------------------------------------------------------------------------'--.--A

Details of Employees with Monthly Wages Above Rs_15000/-

Sr. Est. Cont Occupation Estimated Value of Estimated Table Place 0

No. No. of ract totalsalary food/q rtrsl Total Emplo
Emps Emps Iwages/other other earnings
earnings considerations

1 10 Petrochemical Industry 40,000 40 ,000 A 10 Supervisors

HPCL Mittal nrgy
Ltd. Village
Phulokhari ,
Talwadi saboo
bthinda Punjab

Details of Employees with Monthly Wages Above RS.15000/-

Sr. Est. Cont Occupation Estimated Value of Estimated I Table Place of

No. No. of ract totalsalary food/qrtrs/ Total Employment
Emps Emps /wages/other other earnings

, I
earnings considerations
I
1 35 Petrochem ical Industry 30 ,000 30 ,000 A 35 Inert Technician
atHPCL Mittal nrgy
Ltd . Village
Phulokhari ,
Talwadi saboo
bthinda Punjab

Details of Employees with Monthly Wages Above Rs.15000/-

Sr. Est. /cont Occupation Estimated Value of Estimated Table Place of

No. No. of ract totalsalary food/qrtrs/ Total Employment
Emps IEmps /wages/other other earnings
earnings considerations
I
--.--
1 8 Petrochemical Industry 27,000 27 ,000 A 8 Electricians at
HPCL Mittal nrgy
Ltd . Village
Phulokhari ,
Talwadi saboo
bthinda Punjab

Contract Details

Principal Name
Site of work
Trade description
Address

Illml~~IIIII"l'mllm~g~~e"'" :~:~,:~~; ~::~:~: Limited

Place: MANGALORE

Date 01/01/2021

This is an electronically generated document (Policy Schedule) .Th e

Policy document duly stamped will be sent by post.
~
fbr
~ ~~
______

In case of any query regarding the Policy please ca ll Toll \; . ~

Free No. 1800 11 8485 and 011 33208485 . Authorised Signatory
 This DociJ .·1ent is Digitally Signed

71ST

Attached to and forming part of policy number 422200/48/2021/2495

- - - - - - - - - - - - _ . _ - - - - - - - - - - - - - - - - - - - - - - --'

Details of Employees with Monthly Wages Above RS.15000/·

Sr. Est. Cont ' I occupation

'--~~im ated
lvalue of Estimated Table Place of
No. No. of ract Itotals alary food/qrtrsl Total I Employment
Emps Emps
I/wa 9.e s/other lother I earnings
cC'rni n g._5_ _ -L-:conSiderations
I
1 18 Petrochemical Industry 18,000 18,000 A 18 Drivers at
HPCL Mittal
Energy Ltd . Village
Phulokhari ,
Ta!'vvadi saboc
bthinda Punjab

Details of Employees with Monthly Wages Above RS.15000/·

Sr. Est. Cont Occupation l'Estimated Value of Estimated Table Place of

No. No. of ract totalsalary food/qrtrsl Total Employment
Emps Emps I /Wi:lg.e s/other other earnings
earnings considerations

1 2 Petrochemical Industry 16,000 16,000 A Store Keepers

atHPCL Mittal
energy Ltd . Village
Phulokhari ,
Talwadi saboo
bthinda Punjab

Details of Employees with Monthly Wages Above RS.15000/·

,-
Sr. I Est. Cont Occupation I Esti mated Value of Estimated Table Place of
No. No. of ract I Iota Isalary food/qrtrsl Total
earnings
Employment
Emps Emps I /wag es/other other
, earn ings Iconsiderations
I I

1 6 Petrochemical Industry 16,000 16,000 A mECHANICS AT

HPCL Mittal
Energy Ltd . Village
Phulokhari,
Talwadi sa boo
bthinda Punjab

State
City
Pincode 151 30 1

Place : MAN GALORE

11111111 111111111111111111111111111111111 11111111111111111111111111111111111 For and on behalf of
Date : 01/01/2021 IRDA·REGNO·556 The Oriental In surance Company Limited

q~/?
This is an 1llectronically generated document (Policy Schedule) .Th e
Policy document duly stamped will be sent by post.

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised ~
CIN : U66010DL 1947(,01007158 All the Amounts mentioned in this policy are in Indian Rupee Page 4 of 6

IRDA Regn . No. 556 · Now you can buy and renew sel ected policies online at www.o rienta linsurance .org .in
 This Document is Digitally Signed

. 7 1ST

Attached to and 'forming part of policy number 422200/48/2021/2495

Details of Employees with Monthly Wages Above Rs.15000/-

Sr. Est. Cont Occupation Estimated Value of Estimated Table

No. No. of ract totalsalary food/qrtrs/ Total
Emps Emps /wages/other other earnings
earnings considerations

1 8 Petrochemical Industry 21 ,000 21 ,000 A

Details of Employees with Monthly Wages Below Rs.15000/-

-
Sr. Est. Cont Occupation Estimated Value of Estimated Table Place of
No. No. of ract totalsalary food/q rtrs/ Total Employment
Emps Emps /wages/other other earnings
earnings considerations

1 153 Petrochemical Industry 14,000 14,000 A 153 Catalyst

Helpers at HPCL
Mi"'31 Energy Ltd .
Village Phulokhari ,
Talwadi sa boo
bthinda Punjab

The Insurance under this policy is extended to cover risks of (as per forms attached) .
Total Annual Wages of all Employees *120 times .

Total Premium in words Indian Rupees Forty-Seven Thousand Seven Hundred Only

The Insurance under this policy is subject to Warranties & Clauses (as per forms attached) .

"It is hereby agreed that th is policy doesnot cover medical expenses" as req uired under the provision 2A of thE Vorkmen
Compensation Act , 1923(as amended) and described above .

Subject to adjustment in the terms of Condition 6.The estimated amount of wages/salaries & other earnings on which premium
is based.

It is hereby understood and agreed that any work in connection with horses and/or live stock is expressly excluded from
the indemnity granted under this Policy.
It is hereby understood and agreed that the indemn ity herein is extended to cover th e lega l liability of the insured to
workmen in the employment of c.;ontractors perform ing work for the Insured while engaged in the business and
occupations in respect of which the within Policy is granted, iJut only so f<::r as rega rd claims under th e workmen's

~I II I III IIIIII IIII ~I I I I IIIIII ~ 1I1 1111 1 1!llli~ 1II1

Place : MAN GALORE
11II11I1II11I
Date: 01/01 /2021 IRDA·REGNO·556

This is an electronically generated document (Policy S.::hedule).The

Policy document duly stamped will be sent by post.

In case of any query regarding the Policy please ca ll Toll

Free No. 1800 11 8485 and 011 33208485

CIN : U66010DL 1947GOI007158 !6.11 the Amounts mentione(j in this policy are in Inuian Rupee Pag e 5 of 6

IRDA Regn. No. 556 - Now you can buy and renew selected po:; ::e3 onlino at www .orientalinsurance .org.in
 This Docurr·;>nt is Digitally Signed

7 1ST

Attached to and formir,g part of policy numuf,r ~,L22GO!11)120L112495

- -- ---------

compensation act , 1923 and subsequent ame~Jll1ents of soid Act prior to the date of th e issue of this Policy , the
premium in respect of such extended insurance to be calculated.

SINo Name I ,dress

---_._-----_.
l·iPCL- MIHAL ENERGY LIMITED, VILLAGE PHULOKHARi, TALUKA
TAL'NANOI SABOO BATHINDA, PUNJAB 151301 INDIA

Warranted that in case of dishonour of premium cheque(s) the Company shall not be liable under the policy and the policy shall
be void abinitio (from inception) .

In witness whereof the undersigned being authorised by and on behalf of the Company has/have herein to set his/their hands at
DO MAN GALORE (GSTIN : 29AAACT0627R4ZS) on 01ST DAY OF JANUARY 2021 .

For and on behalf of

Entered By M- qAGHU NAIK B The Oriental Insurance Company Limited

Examined By Ms USHA K

Policy Printed By: 455121 IP :

Authorised Signatory
Policy Printed On : 01-JAN-21 14:44:04 ' MAC :

Place:
111 1 1 1 1 1 I11 I1 111 1I1~111 111 1 1I1 11111I111I1I1 I1 I1I1I1 1111/11 1 1
MAN GALORE
For and on behalf of
Date 01 /01 /2 021 IROA-REGNO-556 The Oriental Insurance Company Limited

This is an electronically generated document (Policy Schedule).The

Policy document duly stamped will be sent by post.

In case of any qu ery regarding Ihl') Policy plNlse call foil

Free No. 1800 11 8485 and 011 33208485 . Authorised Signatory

Clt~ · U66010DL 1947GOi007158 All th e Amount:> ITlcntioned in this policy are in Indian Rupee Page 6 of 6

IRDA Regn. No. 556 - Now yC\) can buy and renew selected policies online at www.orientalinsurance .org .in
 The Oriental Insurance Company Ltd.
DO - MAN GALORE BEAUTY PLAZA BALMATTA ROAD l l l MAN GALORE 575001l

GST NO : 29AAACT0627R4ZS
RECEIPT

\ ~I
Office Code & Name 422200 - DO MAN GALORE Bank Code 9100(C-422200-01 )
Collection No. 51-01/5105005480 Posted Doc No. 5105005480 " I

i
Collection Date 0 1/0 1/2021 14:45 Posted Doc Dt.. 0 1/01/2021
I
Received with thanks From Sh.lSmt.l MIs. PLANT- TECH INDUSTRIAL SERVICES LTD ., I
The Sum of Indian Rupees Forty-Seven Thousand Seven Hundred Only I
Towards the following Pre m ium collections
SI Dept. Policy No. Policy End/Ren/Dec/ Dev. Off. Code Source Amount C/O GL SL Code Pay Bank Bank Instrument Instr. DUCC
No. Code Status Claim No. Code Collected Code Mode Name Branch No. Exp. Dt.
----------
48 202 1/2495 New NZ0000000225 BBOOOOO 47 ,700 .00 C 5083 AAOOOOOOOOOl CHQ State Bank GHS 031619 Ol IO1/2021
Policy 01070 of India ROAD,
(SBI ) MANGALU
RU
Total 47 ,700 .00

GST : Rs . 7276

• 29AABCP9785B1Z2

EMPLOYEES
COMPENSATION

subject to rea lisation of Cheque

CIN : U66010DL 1947GOI0071 58 !RDA Regn. No. 556 - All the amounts mentioned in th is report are in Indian Rupees