Servicing Office Address

Madhubani Branch,Near Suri School Chowk, Gandhi Chowk, Madhubani,

Bihar, Pin : 847211
GSTIN No: 10AAACN9967E3ZG

RECEIPT

Customer Details Collection Details

Name : Mr VIDYA SAGAR Agent Code : 9000187061
Address : S/O RAGHUNATH MAHTO AT PAKHRAUNI Collection Number : 17120381210000003163
KORIYANI TOL PO SAURATH PS RAHIKA Collection Date : 24/09/2021
DIST. MADHUBANI , BIHAR , Bank Account : 9173
Pin Code : 847211

Received with thanks from Sri/Smt Mr VIDYA SAGAR

a sum of 9596 (RUPEES NINE THOUSAND FIVE HUNDRED NINETY SIX ONLY) by CD
towards 1 Year Package Policy Policy as per details given hereunder

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

1 17120331216360002022 11 SGST_BR_Int_Liab 7314 732.00 0.00 732.00

2 17120331216360002022 11 CASH PREMIUM A/C 5083 8132.00 0.00 8132.00

3 17120331216360002022 11 C.D CONTROL A/C 5076 0.00 9596.00 -9596.00

4 17120331216360002022 11 CGST_BR_Int_Liab 7313 732.00 0.00 732.00

TOTAL : 9596.00 9596.00 0.00

Particulars : CD

For National Insurance Company Ltd.,

1.Please quote collection no. and date in all correspondeces
2.The stamp has been defaced and retained at the office against the issued
policy.

Authorised Signatory

NIC/UBPORTAL/ 24/09/2021 03:34 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
 Issuing Office Name & Address
MADHUBANI BRANCH ,
NEAR SURI SCHOOL CHOWK, GANDHI CHOWK, MADHUBANI, BIHAR, PIN
: 847211
Tel: Fax: 06276 222361 (G)
GSTIN No: 10AAACN9967E3ZG

National Insurance Company Ltd.

Registered & Head Office: 3, MIDDLETON STREET, POST BOX NO. 9229, KOLKATA - 700 071
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
Form 51 of the Central Motor Vehicle Rules, 1989
Policy No: 17120331216360002022 1 Year Package Policy from 03:34 PM of 24/09/2021 to Midnight of 23/09/2022
Insured Details
Name : Mr VIDYA SAGAR
Address : S/O RAGHUNATH MAHTO AT PAKHRAUNI KORIYANI TOL PO SAURATH PS RAHIKA DIST. MADHUBANI , BIHAR ,
Pincode : 847211 Telephone : 6287543077 Email : jhashailendrakumar27@gmail.com
PAN No. : GSTIN No. : Aadhar No. :
Channel : SHAILENDRA KUMAR Mobile : 9162382089 Email :
Aadhar : PAN : xxxxxx713G Code. : 171203 / 9000187061
Break-in Approver : J B KANTHA(10777)
Vehicle Details
Make & Model Bajaj Auto Limited BAJAJ MAXIMA BAJAJ MAXIMA DIESE
Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District
BR-07-PC-0601 BBYWKF23636 MD2A95AY8KWF33707 SEDAN 447 2019 1+3 DARBHANGA
Geographical Area : INDIA.
Class of Vehicle Passenger Carrying 3 Wheeler carrying capacity upto 6
FastTag ID
Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV
Rs.1,90,000 - - - - Rs.1,90,000

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

Basic OD Premium 2,416.80 Basic TP Premium 2,595.00
(+) Electrical Access. Premium - (+) Legal Liab.to Driver/Cleaner/Conductor ( 1 No. ) YES 50.00
(+) Bi-fuel kit Loading - (+) Legal Liability to Passenger ( 3 No. ) YES 3,723.00
(+) IMT 23 - (+) Geographical Area Extension -
(+) Geographical Area Extension - (+) NFPP Premium -
(-) Other Discount - -652.54 (+) PA for Driver/Cleaner/Conductor -
(+) Nil Depreciation - (+) PA to owner driver -
(-) NCB Discount (+) Hirer Indemnity Premium -
(+) Towing Charge - (+) Bi-fuel kit Loading -
(-) Discount For Limited TPPD -
OD Total (Rounded Off) 1,764.00 TP Total (Rounded Off) 6,368.00
OD Total (Rounded Off) 1,764.00
TOTAL PREMIUM 8,132.00
GST 1,464.00
NET PAYABLE 9,596.00
Collection Number :17120381210000003163 dated 24-Sep-2021
Subject to IMT Endorsement No. 22,28,40
NIC Transcation Id: Bank Ref No:
Excess : Compulsory: Rs.500 Imposed: Rs.0 Voluntary: Rs.0
Limitation as to use : Use only in connection with insured's business.The Policy does not cover use for a) Organised Racing b) Pace Making c) Reliability Trials d) Speed Testing e) Use whilst drawing a
trailer except the towing (other than for reward) of any one disabled mechanically propelled vehicle.
Drivers Clause : Any person including the insured Provided that the person driving holds an effective and valid driving license to drive the category of vehicle insured hereunder, at the time of
accident and is not disqualified from holding or obtaining such a license. Provided also that a person holding an effective and valid Learner's License to drive the category of vehicle
insured hereunder may also drive the vehicle when not used for transport of passengers at the time of accident and that the person satisfies the requirements of Rule 3 of Motor
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.
Under section 1(ii) Damage to third party property is Upto Rs. 7,50,000 .
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
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".
Financier : SELF OWNED
Prev Policy : Reliance (Pol No: 612121923390004436 Expiry Date: 15/10/2020)
Nominee Name : Relation : Age :
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.
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.

Authorised Signatory
For & On behalf of
National Insurance Company Limited

NIC/UBPORTAL/ 24/09/2021 03:34 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