LIBERTY GENERAL INSURANCE LIMITED

COMPULSORY PERSONAL ACCIDENT COVER FOR OWNER-DRIVER UNDER MOTOR INSURANCE

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
IMPORTANT 1)The Validity of this Certificate of Insurance cum Schedule is subject to realization of the premium cheque.
2) In the event of misrepresentation, fraud or non-disclosure of material facts, the company reserves the right to cancel the
policy from inception.
Policy issuing office :10TH FLOOR, TOWER A, PENINSULA BUSINESS PARK, GANPATRAO KADAM MARG,LOWER PAREL,DELISLE ROAD, MUMBAI,
MAHARASHTRA-400013 Phone:+91 22 6700 1313 Fax: +91 22 6700 1606
Policy Servicing office :10TH FLOOR, TOWER A, PENINSULA BUSINESS PARK, GANPATRAO KADAM MARG,LOWER PAREL,DELISLE ROAD, MUMBAI,
MAHARASHTRA-400013 Phone:+91 22 6700 1313 Fax: +91 22 6700 1606
Policy Number 201910000022720793000000
Policy Issued on 20/05/2022
Period of Insurance From: 00:00 Hrs of 09/06/2022 To: Midnight of 08/06/2023
Ecovernote Number 201910000022720793000000
Geographical Area INDIA
Insured AMARNATH
Address 7B, A.K.B. ASTABANDAN, 4TH CROSS,STREET, SHANTHI NIKETAN,COLONY
EXTN, MADAMBAKKAM, CHENNAI,TAMIL
NADU,KANCHIPURAM,RAJAKILPAKKAM-600073
Customer ID 2159683
Contact Number (M) +91 9952051645
GSTIN No/State NA/TAMIL NADU
UIN Code IRDAN150RP0045V01201819
Agent Name COVERFOX INSURANCE BROKING PVT LTD
Agent Code IMD1022569
Agent Contact No 022-61282100
Sum Insured 1500000
Premium 375.00
IGST(18% - TAMIL NADU) 68
TOTAL POLICY PREMIUM 443.00

VEHICLE DETAILS
S.No. Vehicle Usage Registration Mark Year of Engine No. Chassis No. Make/Model/Type of CC/HP/GVW
/Product & No. Manufacture Body/Fuel
1 PrivateCarPolicy TN-13-B-6057 2015 CJL089616 MEXB15608FT0708 VOLKSWAGEN/POLO/1.2 1198/
07 PETROL
HIGHLINE/Petrol/Hatch
Back

NOMINATION DETAILS
Name of the Nominee Relationship with Insured Name of Appointee (if nominee is minor) Relationship with the Nominee
VAISHALI S SPOUSE NA NA
In witness whereof this Policy has been signed at Mumbai on 20/05/2022
Receipt No: For Liberty General Insurance Limited
In case of claim ,Please contact us at : Toll Free No -18002665844,
Email id – care@libertyinsurance.com
Date of Issue :20/05/2022
Place : MUMBAI
Consolidated Stamp duty has been paid as per letter of Authorization no.
LOA/CSD/333/2022/1779/22 Dated 26/04/2022 issued by Main Stamp Office, Mumbai.
** Not Applicable for the State of Jammu & Kashmir.
Invoice No:
Branch GSTIN :
SAC Code : _______________; Description of Service : General Insurance Service;
Place of Supply : TAMIL NADU/33
IRDA Registration No. 150
CIN No. U66000MH2010PLC209656
Tax is not payable under reverse charge by the recipient
Insurance Limited
Authorised Signatory
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 Vehicle 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 be good.

% DSUnknown
q
1G
1g
0.1 0 0 0.1 9 0 cm
0 J 0 j 4 M []0 d
1i
0g
313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l
100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
h
308 214 170 -164 re
f
0.44 G
1.2 w
1 1 0.4 rg
287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c
478 762 414 786 365 786 c
260 786 245 707 239 652 c
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
h
282 240 170 -164 re
B
Q

Digitally signed by: SACHIN JOSHI

Date: 2022-05-20 18:50:49 IST
Location: Mumbai