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Servicing Office Address

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Soundatti Branch,Ingalagi Building, RS No 778, 779, Old Bus Stand Road, PB

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No: 24 , Soundatti, Belgaum, Karnataka, Pin : 591126
GSTIN No: 29AAACN9967E1ZZ

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RECEIPT

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Customer Details Collection Details

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Name : Miss MAHAMADGOUS YASHIN SUTAGATTI Agent Code : 9000179294

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Address : A/P. GANDHI NAGAR, KOPA MAHALLA. Collection Number : 61050381238000007024
MANOLLI TQ. SAVADATTI DI. BELAGAVI , Collection Date : 06/11/2023

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KARNATAKA , SAVADATTI Bank Account : 9173
Pin Code : 591117

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Received with thanks from Sri/Smt Miss MAHAMADGOUS YASHIN SUTAGATTI

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a sum of 1191 (RUPEES ONE THOUSAND ONE HUNDRED NINETY ONE 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

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38
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1 61050331236760003810 11 C.D CONTROL A/C 5076 0.00 1191.00 -1191.00

2 61050331236760003810 11 60CASH PREMIUM A/C 5083 1009.00 0.00 1009.00

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3 61050331236760003810 11 CGST_KA_Int_Liab 7343 91.00 0.00 91.00

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4 61050331236760003810 11 SGST_KA_Int_Liab 7344 91.00 0.00 91.00

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TOTAL : 1191.00 1191.00 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
in terms of the provisions of the said sub-rule.
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Authorised Signatory
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NIC/UBPORTAL/9000179294 06/11/2023 06:55 PM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
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 Issuing Office Name & Address
SOUNDATTI BRANCH , INGALAGI BUILDING, RS NO 778, 779, OLD BUS STAND
ROAD, PB NO: 24 , SOUNDATTI, BELGAUM, KARNATAKA, PIN : 591126
Tel: 08330 222322 (G) Fax:
GSTIN No: 29AAACN9967E1ZZ

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: 61050331236760003810 2W 1 Year Liability Only from 18:55 Hrs of 06/11/2023 to Midnight of 05/11/2024 IXI
Insured Details

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Name : Miss MAHAMADGOUS YASHIN SUTAGATTI

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Address : A/P. GANDHI NAGAR, KOPA MAHALLA. MANOLLI TQ. SAVADATTI DI. BELAGAVI , KARNATAKA , SAVADATTI

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Pincode : 591117 Telephone : 8971722386 Email : devarajgamanagatti@gmail.com

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

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Channel : DEVARAJ V GAMANAGATTI Mobile : 8105968789 Email : devarajgamanagatti@gmail.com

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Aadhar : PAN : xxxxxx692M Code. : 610503 / 9000179294

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Vehicle Details
Make & Model Two Wheeler Yamaha RX 135

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

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KA-28-J-7120 1L5249990 99F1L5249990 132 2007 1+1 Bijapur (KTK)

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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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- - - - - -

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

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Basic OD Premium Basic TP Premium 714.00

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(+) Geographical Area Extension - (+) Geographical Area Extension :19 -
(-) Vol. Excess Discount - (+) WC for Driver -
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(-) Auto. Assoc Discount - (+) PA to owner driver YES 295.00

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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) 1,009.00

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

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(+) Nil Depreciation Plus - TOTAL PREMIUM 1,009.00

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(+) NCB Protect - GST 182.00

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(+) Engine Protect - NET PAYABLE 1,191.00

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(+) Invoice Protect - Collection Number :61050381238000007024 dated 06-Nov-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
making (e) Speed Testing and Reliability Trials (f) Use in connection with Motor Trade
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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
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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.

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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. 1,00,000 . PA Cover under section 3 for owner-driver is Rs. 15,00,000.
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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 : YASHIN Relation : FATHER Age : 50 Years

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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/9000179294 06/11/2023 06:55 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