Service Branch Address: No.4B, 4th Floor, "" A"" Block, Mena Kampala Arcade,Sir Theyagaraya Road, T.Nagar.

July 14, 2022

.
Mr.CHINNI SRINIVASARAO
9-366, RAJAKAPETA, Intermediary Code: OA902100
THADEPALLI, GUNTUR,
522501. Intermediary Name: Internal agent
Telephone :
Mobile : xxxxxx9541

CERTIFICATE OF INSURANCE & POLICY SCHEDULE

(See Form 51 of The Central Motor Vehicles Rules, 1989) Motor Vehicles Act, 1988
1 Year Three Wheeler Policy – Liability only
Policy Period: Period Of Insurance
Certificate of Insurance and Policy No.
VMLI089076000100 From 14:27:23 hours on 16/07/2022 To 23:59:59 hours on 15/07/2023
INSURED DETAILS
Insured Date Geographical Registration Registration
Name of Insured Business/Profession
of Birth Area Authority Date
Mr.CHINNI
CHINNI SRINIVASARAO India GUNTUR 06/05/2000

VEHICLE DETAILS
BAJAJ RE AUTORIKSHAW
Registration Number AP16X2035 Model Description 3 WHEELER
Engine Number AEMBFM09324 Type of Body HACKNEY
Chassis Number 24FBFM17837 Cubic Capacity 417
Make of the Vehicle BAJAJ AUTO LTD Year of Manufacture 2000
Seating Capacity 4 Total Premium(in Rs.) 7842.52
DRIVER: Any person including the Insured:• Provided that a person driving holds an
LIMITATIONS AS TO USE:The Policy covers use of the vehicle for any purpose
effective driving license at the time of the accident and is not disqualified from holding or
other than: a) Hire or Reward b) Tution c) Carriage of goods (other than samples or
obtaining such a license. • Provided also that the person holdingng an effective Learner’s
personal luggage) d) Organised racing e) Pace making f) Speed testing g) Reliability
License may also drive the vehicle and that such a person satisfies the requirements of
Trials h) Any purpose in connection with
ith Motor Trade
Rule 3 of The Central Motor Vehicles Rules, 1989.
LIMITS OF LIABILITY:Under Section II-11 (i) of the Policy - Death of or bodily injury - Such amount as is necessary to meet the requirements of the Motor Vehicles Act, 1988. Under Section II-1
II 1 (ii) of the
Policy -Damage to Third Party Property - Rs Rs.1,00,000Personal Accident cover for Owner - Driver under section III: CSI Rs. 15,00,000.00

Nominee Name : Nominee Age : Relationship with :

Guardian Name : Guardian Age : Guardian Relation :
LIABILITY
1. Basic premium including premium for TPPD 6318.00
2. Less: TPPD restricted to statutory limit of Rs.6000/
Rs.6000/- (Endt. IMT. 20) 0.00
3. Bi-fuel kit (CNG/LPG) 0
Add:
4. PA to Paid Driver CSI Rs. (IMT 17) 0.00
5. Geographical Area Extn.Endt.IMT-1 0.00
6. PA cover for Owner - Driver under Section III CSI Rs. 15,00,000.00 375.00
7. PA to Unnamed Passengers (IMT 16) 0.00
8. Enhanced PA for Unnamed Passengers, CSI Rs. 0 0.00
9. Enhanced PA for Owner Driver, CSI Rs. 0 0.00
10. Enhanced PA for Paid Driver, CSI Rs. 0 0.00
Legal Liability ADD: IGST
1214.00
11. Legal Liability To Paid Driver (IMT 28) 50.00
12. Legal Liability To Employees (IMT 29) 0.00
TOTAL LIABILITY PREMIUM (B) 6743.00 7957.00
7957
Subject to IMT Endt. Nos. & memorandum 22 (refer Terms & Conditions for relevant wording)
In Witness whereof this Policy has been signed at Chennai on in lieu of Cover note No. dated Receipt No. .Subject
Subject to IMT Endt. Nos & Memorandum . 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 Ch
Chapter
apter XI of the Motor Vehicles Act, 1988.
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 reason 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
AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY" under Policy
Terms and Conditions.

rised Signatory
Consolidated Stamp Duty Paid to Govt of TamilNadu This document is digitally signed, hence counter signature / stamp is not required.
For Legal interpretation, English version will hold good. ServiceTaxNo: AABCR7106GST001 UIN: PAN Number : AABCR7106G

Document Code:
Fastag ID:
 GST Invoice
Royal Sundaram General Insurance Co. Limited
No.4B, 4th Floor, "" A"" Block, Mena Kampala Arcade
Sir Theyagaraya Road, T.Nagar,

GSTIN : 33AABCR7106G1ZQ

Policy Number : VMLI089076000100

GST Invoice Number : VMLI08907600000
Inception Date : 16/07/2022 12:00:00
Policy Posted Date : 14/07/2022 02:27:23

Address of insured:
KRISHNA, Andhra Pradesh
9-366, RJAJAKAPETA,
THADEPALLI, GUNTUR
State:Andhra PradeshPincode: 522501.

Accounting code of service : 997314

Description of service: Motor vehicle insurance services

Taxable premium 6743.00

Add: IGST 18% 1214.00

Gross Premium 7957.00

Indication if tax payable under reverse charge - No

Note: “This document is digitally signed.