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Issuing Office Name & Address

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Mumbai Direct Agents Branch II,First Floor, Sterling Cinema Building, 65,

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Murzaban Street, Fort, Mumbai, Pin : 400001 ,Telephone No: 18003450330

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Email ID: phonepe.tieup@nic.co.in
GSTIN No: 27AAACN9967E1Z3

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RECEIPT

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Customer Details Collection Details

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Name : ANUPKUMAR G EKBOTE Agent Code : 91067500000001

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Mobile No : 9591431809 Collection Number : 26020181235000350156
Email : anupge@gmail.com Collection Date : 07/11/2023

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Bank Account : 9100

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Received with thanks from Sri/Smt ANUPKUMAR G EKBOTE

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a sum of 883 (RUPEES ) by ONLINE

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towards 1 Year Package Policy 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

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No. Year Number (General Ledger) Received

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1 26020131236230354116 11 CASH PREMIUM A/C 5083 748.00 0.00 748.00

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2 26020131236230354116 11 IGST_KA_Int_Liab 7345 135.00 0.00 135.00
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TOTAL : 883.00 0.00 883.00

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Particulars : ONLINE
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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.
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Authorised Signatory
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NIC/PHONEPE/91067500000001 07/11/2023 03:51 P.M.

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
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 Issuing Office Name & Address
MUMBAI DIRECT AGENTS BRANCH II , FIRST FLOOR, STERLING CINEMA
BUILDING, 65, MURZABAN STREET, FORT, MUMBAI, PIN : 400001
Telephone No: 18003450330 Email ID: phonepe.tieup@nic.co.in
GSTIN No: 27AAACN9967E1Z3

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

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Policy No: 26020131236230354116 1 Year Package Policy from 00:00 Hrs of 08/11/2023 to Midnight of 07/11/2024 IXI

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Insured Details

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Name : ANUPKUMAR G EKBOTE

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Mobile No : 9591431809 Email : anupge@gmail.com

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PAN No. : GSTIN No. :

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Channel : PHONEPE INSURANCE BROKING SERVICES PRIVATE LIMITED Tele. No: 080-68727888 Email : support@phonepe.com

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Aadhar : PAN : xxxxxx058K Code. : 260201 / 91067500000001

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Vehicle Details

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Make & Model 2W HONDA ACTIVA 6G STANDARD

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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-27-EB-1723 JF48E80079882 ME4JF481MD8079869 SCOOTER 110 2014 1+1 HAVERI

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Geographical Area : INDIA.

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Registration Date : 23/01/2014

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Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV
Rs.19,568 - - - - Rs.19,568

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OD Premium Breakup in Rs. TP Premium Breakup in Rs.
Basic OD Premium 275.52 Basic TP Premium 714.00

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(+) Geographical Area Extension - (+) Geographical Area Extension -
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(-) 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 - -206.64 (-) Discount For Limited TPPD -

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(-) NCB Discount 50% -34.44 TP Total (Rounded Off) 714.00

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(+) Nil Depreciation - OD Total (Rounded Off) 34.00

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(+) Nil Depreciation Plus - TOTAL PREMIUM 748.00

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(+) NCB Protect - GST 135.00

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(+) Engine Protect - NET PAYABLE 883.00

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(+) Invoice Protect - Collection Number :26020181235000350156 dated 07-Nov-2023

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OD Total (Rounded Off) 34.00 Subject to IMT Endorsement No. 16,22,22A,29

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Excess : Compulsory: Rs. 100 Imposed: Rs.0 Voluntary: Rs. 0

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Limitation as to use : Use only for social, domestic and pleasure purposes and for the insured's business or profession. The Policy does not cover use for hire or reward, tuition, racing, pace making,
reliability trial, speed testing, carriage of goods(other than samples or personal luggage) in connection with any trade or business or use for any purpose in connection with Motor
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Trade
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Drivers Clause : Any person including the insured Provided that a person driving holds an effective driving license at the time of the accident and is not disqualified from holding or obtaining such a
license, Provided also that the person holding an effective Learner's license may also drive the vehicle and that such a person satisfies the requirements of Rule 3 of the Central
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Motor 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 .
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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 the reason of wider terms
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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
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RIGHT OF RECOVERY" No Claim Bonus will only be allowed, provided the policy is renewed within 90 days of the expiry of the previous policy. No Claim Bonus is subject to no
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claim on the previous policy. Benefits under the policy stands forfeited if claim is/was made in previous policy. For legal interpretation, the English version will hold good.
FINANCIER NAME :
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Prev Policy : National Insurance Company Limited (Pol No: 26020131226230259164 Expiry Date: 07/11/2023)
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Nominee Name : Relation : Age :

Transaction Date : 07/11/2023 00:00:00 Transaction Number : VF2311071557027088661718 Inspection ID :
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Disclaimer Note : It is warranted that IN CASE OF DISHONOUR OF THE PREMIUM CHEQUE, THIS DOCUMENT STANDS AUTOMATICALLY CANCELLED 'AB-INITIO'.
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In the event of misrepresentation, fraud or non-disclosure of material fact, the Company reserves the right to cancel the Policy. The policy is issued based on the information provided by you, which is available
with the company. In case of discrepancy/non recording of relevant information in the policy, the insured is requested to bring the same to the notice of the company within 15 days. This Policy is to be read in
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conjunction with the Policy wordings available on the website https://nationalinsurance.nic.co.in of the Company. On renewal, the benefits provided under the policy and/or terms and conditions of the policy
including premium rate may be subject to change.
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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
For & On behalf of
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National Insurance Company Limited

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NIC/PHONEPE/91067500000001 07/11/2023 03:51 P.M.

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
 Issuing Office Name & Address
MUMBAI DIRECT AGENTS BRANCH II , FIRST FLOOR, STERLING CINEMA
BUILDING, 65, MURZABAN STREET, FORT, MUMBAI, PIN : 400001
Telephone No: 18003450330 Email ID: phonepe.tieup@nic.co.in
GSTIN No: 27AAACN9967E1Z3

PROPOSAL FORM
PROPOSER'S DETAILS
Name ANUPKUMAR G EKBOTE
Mobile No 9591431809 email id anupge@gmail.com

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Nominee's Name Relation Nominee's Age

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VEHICLE DETAILS

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Model Two Wheeler HONDA ACTIVA 6G STANDARD Year of Make 2014

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Reg No KA-27-EB-1723 Engine No JF48E80079882 Chassis No ME4JF481MD8079869

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Reg. Date 23/01/2014 Fuel PETROL

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Financier FastTag ID
IDV Rs. Rs.19,568

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Accessories Electrical Rs. - NIL Non-Electrical Rs. - NIL Bi-fuel Kit Rs. - NIL
POLICY/COVERAGE OPTION DETAILS

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Type of Policy/Cover Required Two Wheeler 1 Year Package Policy

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Policy Number 26020131236230354116

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Policy (period) from 00:00 Hrs of 08/11/2023 to Midnight of 07/11/2024

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CPA Owner/Driver NOT OPTED

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Add-ons Included NOT OPTED

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PREMIUM DETAILS

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Total OD Premium Rs. 34.00 Total TP Premium Rs. 714.00 GST Rs. 135.00 Premium Payable Rs. 883.00

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PREVIOUS POLICY DETAILS *
Previous Policy Type PACKAGE Previous Policy Expiring on :00 07/11/2023
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Previous Policy No 26020131226230259164 issued by National Insurance Company Limited

Previous NCB % -50 Claims reported in Previous Policy
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Declaration by the Insured

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I. I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my/our knowledge and belief and I/We hereby agree
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that this declaration shall form the basis of the contract between me/us and National Insurance Company Ltd. I/We also declare that if any additions or
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alterations are carried out after the submission of this proposal form then the same would be conveyed to National Insurance Company immediately.
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II. It is declared that vehicle is not imported.

III. I/We hereby declare that the vehicle proposed for insurance has not met with an accident during the period of break in insurance. Any liability arising during
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this period of break will not be admissible under the policy. The vehicle proposed for insurance is in existence and is roadworthy at the time of taking the policy.
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IV. I/We hereby declare that the vehicle proposed for insurance has a valid Pollution Under Control Certificate & Fitness Certificate (in case of transport
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vehicles) on the date of fresh issuance / renewal of the policy.

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V. I/We hereby declare that the rate of NCB claimed by me/us is correct and that no claim has arisen in the expiring policy period. I/We further undertake that if
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this declaration is found to be incorrect, all benefits under the policy in respect of Section I of the Policy will stand forfeited.
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VI. Any changes to the details post payment might require additional payment.
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VII. Claim can be denied by the Insurer if the declaration made by you about claims & NCB in previous policy is found to be incorrect.
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VIII. Previous year policy copy and PUC certificate may be asked by the insurance company at the time of claim.
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IX. In case of any premium difference due to any incorrect information provided including but not limited to vehicle/previous policy related dates, the premium
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difference will be borne by the customer.

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X. Your IDV should be 10% less than Previous Year Policy IDV or as per depreciation norms of Indian Motor Tariff. In case of a total loss claim or a theft claim,
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the purchase invoice will also be taken into consideration for the vehicle's final valuation (as per the depreciation).
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XI. If vehicle class selected above is found to be incorrect at any time during the policy, the policy shall be cancelled without any refund and all rights to recover
there under in respect of past or future accidents shall forfeit.
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XII. I/We also declare that details regarding previous year NCB, past claims history and ownership transfer during past 12 months are true and if found to be
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false at any time during the policy, the policy shall be void and all rights to recover there under in respect of past or future accidents shall forfeit.
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XIII. I/We agree and understand the provision of Section 41 Insurance Laws (Amendment) Act, 2015, Prohibition of Rebates: 1) No person shall allow or offer
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to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives
or property in India, any rebate of the whole or part of the commission payable or any rebate of premium shown on the policy, nor shall any person taking out
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or renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the published prospectus or tables of the
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insurer. 2) If any person fails to comply with the provisions of this section, s/he shall be liable to payment of a fine which may extend to Ten Lakh rupees.
XIV. I/We confirm that my Vehicle will be re-registered as per statutory requirement (whenever the RC is about to cross the validity period), failing which the
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policy will not be considered valid.

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Date : 07/11/2023
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This Proposal form has been electronically accepted

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NIC/PHONEPE/ 91067500000001 07/11/2023 03:51 P.M.

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