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Servicing Office Address

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Dharamshala Branch,267, Civil Lines, Near Kangra Central Co-Op Bank,

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Head Office, Dharamshala, Kangra, Himachal Pradesh, Pin : 176215
GSTIN No: 02AAACN9967E2ZE

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RECEIPT

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Customer Details Collection Details

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Name : Mr RAVINDER SINGH Agent Code : 9000144058

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Address : S/O SH DHARM SINGH VPO HARNERA TEH Collection Number : 42120281238000004731
SHAHPUR DISTT KANGRA , HIMACHAL Collection Date : 09/08/2023

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PRADESH , SHAHPUR Bank Account : 9174
Pin Code : 176206

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Received with thanks from Sri/Smt Mr RAVINDER SINGH

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a sum of 1612 (RUPEES ONE THOUSAND SIX HUNDRED TWELVE ONLY) by CD
towards 1 Year Liability Only Policy as per details given hereunder

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Sl Policy Number TR Code End/Ren/Dec/Clm End/Ren/Dec/Clm A/C Particulars A/C Head Credit Amount Debit Amount Amount
No. Year Number (General Ledger) Received

78
25
00
1 42120231236760002578 11 C.D CONTROL A/C 5076 0.00 1612.00 -1612.00

0
2 42120231236760002578 11
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CASH PREMIUM A/C 5083 1366.00 0.00 1366.00
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3 42120231236760002578 11 CGST_HP_Int_Liab 7334 123.00 0.00 123.00

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4 42120231236760002578 11 SGST_HP_Int_Liab 7335 123.00 0.00 123.00

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TOTAL : 1612.00 1612.00 0.00

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Particulars : CD
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For National Insurance Company Ltd.,

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1.Please quote collection no. and date in all correspondeces

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2.The stamp has been defaced and retained at the office against the issued
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policy.
3.We hereby declare that though our aggregate turnover in any preceding
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financial year from 2017-18 onwards is more than the aggregate turnover
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notified under sub-rule (4) of rule 48, we are not required to prepare an invoice
Authorised Signatory
in terms of the provisions of the said sub-rule.
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NIC/UBPORTAL/9000144058 09/08/2023 04:01 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
 Issuing Office Name & Address
DHARAMSHALA BRANCH , 267, CIVIL LINES, NEAR KANGRA CENTRAL CO-OP
BANK, HEAD OFFICE, DHARAMSHALA, KANGRA, HIMACHAL PRADESH, PIN :
176215
Tel: 01892 223287 (G) Fax:
GSTIN No: 02AAACN9967E2ZE

National Insurance Company Ltd.

Registered & Head Office: PREMISES NO.18-0374, PLOT NO. CBD-81, NEW TOWN, KOLKATA-700156
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
Form 51 of the Central Motor Vehicle Rules, 1989
Policy No: 42120231236760002578 2W 1 Year Liability Only from 15:47 Hrs of 09/08/2023 to Midnight of 08/08/2024 IXI
Insured Details

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Name : Mr RAVINDER SINGH

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Address : S/O SH DHARM SINGH VPO HARNERA TEH SHAHPUR DISTT KANGRA , HIMACHAL PRADESH , SHAHPUR

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Pincode : 176206 Telephone : 7347514835 Email : ranarajinder19@gmail.com

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PAN No. : GSTIN No. : Aadhar No. :

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Channel : SANJAY KUMAR Mobile : 9805069449 Email : sanjayshahpurd21@gmail.com

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Aadhar : PAN : xxxxxx493M Code. : 421202 / 9000144058

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Vehicle Details
Make & Model Two Wheeler TVS APACHE RTR 160 2V RM DRUM

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Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District

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HP-40-B-2532 OE4F92199887 MD634KE4792F94107 159 2009 1+1 KANGRA

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Geographical Area : INDIA.

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FastTag ID : .

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Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV

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OD Premium Breakup in Rs. TP Premium Breakup in Rs.

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Basic OD Premium Basic TP Premium 1,366.00

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(+) Geographical Area Extension - (+) Geographical Area Extension :31 -
(-) Vol. Excess Discount - (+) WC for Driver -
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(-) Auto. Assoc Discount - (+) PA to owner driver -

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(-) Anti-theft Discount - (+) PA to unnamed PAX -

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(-) Other Discount - (-) Discount For Limited TPPD -

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(-) NCB Discount TP Total (Rounded Off) 1,366.00

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(+) Nil Depreciation - OD Total (Rounded Off)

(+) Nil Depreciation Plus - TOTAL PREMIUM 1,366.00
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(+) NCB Protect - GST 246.00

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(+) Engine Protect - NET PAYABLE 1,612.00

(+) Invoice Protect - Collection Number :42120281238000004731 dated 09-Aug-2023
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OD Total (Rounded Off) Subject to IMT Endorsement No. 24,25

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Excess : Compulsory: Rs. 0 Imposed: Rs. 0 Voluntary: Rs. 0

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Limitation as to use : The Policy covers use of the Vehicle for any purpose other than (a) Hire or Reward (b) Carriage of Goods(other than samples or personal luggage) (c) Organized racing (d) Pace
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making (e) Speed Testing and Reliability Trials (f) Use in connection with Motor Trade
Drivers Clause : Any person including Insured Provided that a person driving holds an effective driving licence at the time of the accident and is not disqualified from holding or obtaining such a
02

licence. Provided also that the person holding an effective Learner's Licence may also drive the vehicle and such a person satisfies the requirements of Rule 3 of Central Motor
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Vehicles Rules, 1989.

Limits of Liability Clause: Under section 1(i) Such amount as is necessary to meet the requirements of the motor vehicle act 1988.
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Under section 1(ii) Damage to third party property is Upto Rs. 1,00,000 .
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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 reasons of wider terms
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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". For legal interpretation, English version will hold good.
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UIN : IRDAN058P0036V01100001
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Financier : SELF OWNED

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Prev Policy : Not Available

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Nominee Name : Relation : Age :

No

NOTE : Warranted that in case of dishonour of the premium cheque, this document stands automatically cancelled 'AB-INITIO'.
Policy stamp to be defaced at the respective policy servicing office.
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TP Rate Revision Notice: For all policies having an effective date on or after 1st April 2023, the TP premium is subject to revision as may be notified by the IRDAI.
The Insured should contact and submit the difference of premium to the policy issuing office on issuance of such notification by IRDAI.
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I/We hereby certify that this Certificate cum Schedule of Insurance is issued in accordance with the provisions of chapter X and chapter XI of Motor Vehicles Act,1988.
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Authorised Signatory
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For & On behalf of

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National Insurance Company Limited

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NIC/UBPORTAL/9000144058 09/08/2023 04:01 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
Customer Care Toll Free Number: 1800 345 0330 Email: customer.support@nic.co.in