Service Branch Address: First Floor, Building # 4,4 Cross Road,Dehradun - 248001 (Uttra Khand),Dehradun,Uttarakhand

Mrs. Arti
W / O GAURAV KARNWAL, 14 / 29 Intermediary Code: BR501650
VASHU STATE, JAKHAN CANAL Intermediary Name: Invictus Insurance Broking
DEHRADUN, UTTARAKHAND
248001 Pvt Ltd
Telephone : Contact: 1800-266-0101
Mobile : xxxxxx1604

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.
VPTP403622000100
From 15:05:45 hours on 18/08/2023 To 23:59:59 hours on 17/08/2024
INSURED DETAILS
Name of Insured Geographical Registration
Business/Profession Registration Date
Area Authority
Mrs. Arti INDIA DEHRADUN 27/07/2007
VEHICLE DETAILS
SANTRO XING XO ERLX
Registration Number UA-07-T-1510 Model Description Gross Vehicle Weight(Kgs) 0
- EURO III - 5 SEATER
Engine Number G4HG7M159353 Type of Body HATCHBACK Seating Capacity (including Driver) 5
Chassis Number MALAB561HR7M127816 Cubic Capacity 1086
Make of the Vehicle HYUNDAI MOTORS LTD. Year of Manufacture 2007 Total Premium (in Rs.) 4,030.88
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 : Nominee Age : Relationship with :
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 0.00
6. Named Passengers, CSI Rs.0 each as per list attached (IMT 15) 0.00
7. Unnamed Passengers, CSI Rs.0.00 0.00
8. Geographical Area Extn.Endt.IMT-1 0.00
9. P.A Cover to Paid Driver, CSI Rs.0.00 (IMT 17)
0.00
Number of Persons-1
ADD:Legal Liability ADD: SGST 307.44
10.To Paid Driver (IMT 28) 0.00 ADD: CGST 307.44
11.To Employees (IMT 29) 0.00
TOTAL LIABILITY PREMIUM 3,416.00 TOTAL PREMIUM 4,030.88
Subject to IMT Endt. Nos. & memorandum 22 (refer Terms & Conditions for relevant wording)
In Witness whereof this Policy has been signed at Chennai on 18/08/2023 in lieu of Cover note No. IMC1719762 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.
Signature Not
For Royal Sundaram General Insurance Co. Limited
Verified
Digitally signed by
TAIKAD MAHADEVAN
Authorised Signatory
SHYAMSUNDER
Consolidated Stamp Duty Paid to Govt of TamilNadu This document is digitally signed, hence counterDate:
signature / stamp is not required.
2023.08.16
15:05:59 GMT+05:30
For Legal interpretation, English version will hold good. GSTIN: 05AABCR7106G1ZP UIN: IRDAN102P0004V02201617 PAN Number:
Reason: For AABCR7106G
RoyalSundaram
a91526ae51deb2de0984e56a02d90cb7 Location: Chennai

Document Code:
Fastag ID:
 GST Invoice
Royal Sundaram General Insurance Co. Limited
First Floor, Building # 4
4 Cross Road
Dehradun - 248001 (Uttra Khand)
GSTIN: 05AABCR7106G1ZP

Policy Number : VPTP403622000100

GST Invoice Number : VPTP40362200000
Inception Date : 18/08/2023
Policy Posted Date : 16/08/2023 15:05:45

Address of insured (Interstate):

W / O GAURAV KARNWAL, 14 / 29
VASHU STATE, JAKHAN CANAL
DEHRADUN
State:UTTARAKHAND
Pincode: 248001

Accounting code of service : 997134

Description of service: Motor vehicle insurance services

Taxable premium 3,416.00

SGST 9% 307.44

CGST 9% 307.44

Gross premium 4,030.88

Indication if tax payable under reverse charge - No

"I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the
aggregate turnover notified under the sub-rule(4) of rule 48, we are not required to prepare an invoice in terms of the provisions of
the said sub-rule.":’
Note:“This document is digitally signed”