Service Branch Address: SCO 82, I & II Floor, ,Sector 40-C, Chandigarh 160 040,Chandigarh 160 040,Chandigarh Branch,Chandigarh

Mr. MANGAT RAM

HOUSE NO : 126, WARD NO : 05 Intermediary Code: BR501650
BARRIAN, UDHAMPUR Intermediary Name: Invictus Insurance Broking
UDHAMPUR, JAMMU KASHMIR
182101 Pvt Ltd
Telephone : Contact: 1800-266-0101
Mobile : xxxxxx8184

CERTIFICATE OF INSURANCE & POLICY SCHEDULE

(See Form 51 of The Central Motor Vehicles Rules, 1989) Motor Vehicles Act, 1988
Private Car Policy – Liability only
Policy Period:Period of insurance
Certificate of Insurance and Policy No.
VPTP307650000100
From 11:50:57 hours on 02/08/2022 To 23:59:59 hours on 01/08/2023
INSURED DETAILS
Name of Insured Geographical Registration
Business/Profession Registration Date
Area Authority
Mr. MANGAT RAM INDIA UDHAMPUR 08/03/2020
VEHICLE DETAILS
Registration Number JK-14-G-5119 Model Description TIAGO XZ - 5 SEATER Gross Vehicle Weight(Kgs) 0
Engine Number REVTRN02GSYK35985 Type of Body HATCHBACK Seating Capacity (including Driver) 5
Chassis Number MAT626281HKG44898 Cubic Capacity 1199
Make of the Vehicle TATA MOTORS LTD. Year of Manufacture 2020 Total Premium (in Rs.) 4,756.58
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) Carriage of goods (other than samples or personal
obtaining such a license. • Provided also that the person holding an effective Learner’s
luggage) c) Organised racing d) Pace making e) Speed testing f) Reliability Trials g) Any
License may also drive the vehicle and that such a person satisfies the requirements of
purpose in connection with Motor Trade.
Rule 3 of The Central Motor Vehicles Rules, 1989.
LIMITS OF LIABILITY:
Under Section I-1 (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 I-1 (ii) of the
Policy -Damage to Third Party Property - Rs Rs.7,50,000-In respect of any one claim or series of claims arising out of one event/-
Nominee Name : MUNSHI RAM Nominee Age : 66 Relationship with : FATHER
Guardian Name : Guardian Age : Guardian Relation :
LIABILITY
1. Basic premium including premium for TPPD 3,416.00
2. Less: For restricted TPPD cover for Rs.6000/- (IMT 20) 0.00
3. Trailers (IMT30) 0.00
4. Bi-fuel kit (CNG) 0.00
Add:Personal Accident Benefits
5. Under Section III (Owner Driver), CSI Rs. 15,00,000.00 315.00
6. Named Passengers, CSI Rs.0 each as per list attached (IMT 15) 0.00
7. Unnamed Passengers, CSI Rs.100,000.00 250.00
8. Geographical Area Extn.Endt.IMT-1 0.00
9. P.A Cover to Paid Driver, CSI Rs.0.00 (IMT 17) 0.00
ADD:Legal Liability ADD: IGST 725.58
10.To Paid Driver (IMT 28) 50.00
11.To Employees (IMT 29) 0.00
TOTAL LIABILITY PREMIUM 4,031.00 TOTAL PREMIUM 4,756.58
Subject to IMT Endt. Nos. & memorandum 16,22,28 (refer Terms & Conditions for relevant wording)
In Witness whereof this Policy has been signed at Chennai on 02/08/2022 in lieu of Cover note No. IMC1164881 dated . 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 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 OF CERTAIN TERMS AND RIGHT OF RECOVERY" under Policy
Terms and Conditions.
For Royal Sundaram General Insurance Co. Limited
Signature Not
Verified
Digitally signed by
TAIKAD MAHADEVAN
SHYAMSUNDER
Date: 2022.07.31
11:50:58 GMT+05:30
Reason: For
* RoyalSundaramAuthorised Signatory
CPA cover for owner driver will expire on 01/08/2023 Location: Chennai
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. GSTIN: 04AABCR7106G1ZR UIN: IRDAN102P0004V02201617 PAN Number: AABCR7106G
f3fe522df66e5e2513b0d89cde782ef0

Document Code:
Fastag ID:
 GST Invoice
Royal Sundaram General Insurance Co. Limited
SCO 82, I & II Floor,
Sector 40-C, Chandigarh 160 040
Chandigarh 160 040
GSTIN: 04AABCR7106G1ZR

Policy Number : VPTP307650000100

GST Invoice Number : VPTP30765000000
Inception Date : 02/08/2022
Policy Posted Date : 31/07/2022 11:50:57

Address of insured (Interstate):

HOUSE NO : 126, WARD NO : 05
BARRIAN, UDHAMPUR
UDHAMPUR
State:JAMMU KASHMIR
Pincode: 182101

Accounting code of service : 997134

Description of service: Motor vehicle insurance services

Taxable premium 4,031.00

IGST 18 % 725.58

Gross premium 4,756.58

Indication if tax payable under reverse charge - No

Note:“This document is digitally signed”