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Servicing Office Address

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Madhepura Branch,State Bank of India Road, Madhepura, Bihar, Pin : 852113
GSTIN No: 10AAACN9967E3ZG

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RECEIPT

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Customer Details Collection Details

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Name : Mr MUKESH KUMAR Agent Code : 9000167038

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Address : S/O-PUSHPATTI JHA AT.+PO.-MURLI PS. Collection Number : 17070481230000006789
-KISHANPUR DISTT. -SUPAUL , BIHAR , Collection Date : 29/03/2024

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Pin Code : 852105 Bank Account : 9173

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Received with thanks from Sri/Smt Mr MUKESH KUMAR

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a sum of 1603 (RUPEES ONE THOUSAND SIX HUNDRED THREE ONLY) by CD

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towards National Stand Alone OD 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 17070431236860003705 11 C.D CONTROL A/C 5076 0.00 1603.00 -1603.00
00
60
2 17070431236860003705 11 CASH PREMIUM A/C 5083 1359.00 0.00 1359.00
68

3 17070431236860003705 11 CGST_BR_Int_Liab 7313 122.00 0.00 122.00

23

4 17070431236860003705 11 SGST_BR_Int_Liab 7314 122.00 0.00 122.00

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TOTAL : 1603.00 1603.00 0.00

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Particulars : CD
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No

For National Insurance Company Ltd.,

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
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
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in terms of the provisions of the said sub-rule.

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Authorised Signatory
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NIC/UBPORTAL/9000167038 30/03/2024 12:07 AM

Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
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 Issuing Office Name & Address
MADHEPURA BRANCH , STATE BANK OF INDIA ROAD, MADHEPURA, BIHAR, PIN :
852113
Tel: Fax: 06476 222080 (G)
GSTIN No: 10AAACN9967E3ZG
RSA Service Provider: M/s ki MOBILITY SOLUTIONS PRIVATE LIMITED
RSA Service Provider Toll Free Number :- 1800 570 1906
For feedback to RSA:- Email: rsa.service@tvs.in

National Insurance Company Ltd.

Registered & Head Office: PREMISES NO.18-0374, PLOT NO. CBD-81, NEW TOWN, KOLKATA-700156
Policy No: 17070431236860003705 2W 1 Year OD Only from 23:17 Hrs of 29/03/2024 to Midnight of 28/03/2025
Insured Details

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Name : Mr MUKESH KUMAR

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Address : S/O-PUSHPATTI JHA AT.+PO.-MURLI PS. -KISHANPUR DISTT. -SUPAUL , BIHAR ,

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Pincode : 852105 Telephone : 9470841080 Email : mjha2257@gmail.com

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PAN No. : GSTIN No. : Aadhar No. : xxxx xxxx 7052

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Channel : MRITYUNJAY KUMAR Mobile : 9534931017 Email : kumarmritujay613@gmail.com

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Aadhar : PAN : xxxxxx314A Code. : 170704 / 9000167038

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Token No :20240329173115635473 Approver : LOK RANJAN(73452) Remarks : APPROVED

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Vehicle Details

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Make & Model Two Wheeler Hero Destini 125 BS-4

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-20
Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District
BR-50-V-9274 125 2022 1+1 SUPAUL

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JF17ELLGM08386 MBLJFW245MGA01537

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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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Rs.65,000 - - - - Rs.65,000

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Premium Breakup in Rs.

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Basic OD Premium 1,089.40 (+) Geographical Area Extension -

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(-) Vol. Excess Discount - (-) Auto. Assoc Discount -
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(-) Anti-theft Discount - (-) Other Discount - -111.12
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(-) NCB Discount (+) Nil Depreciation -

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(+) Nil Depreciation Plus YES 371.00 (+) NCB Protect -

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(+) Engine Protect - (+) Invoice Protect -

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(+) RSA Protect - YES

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TOTAL PREMIUM 1,359.00 GST 244.00

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NET PAYABLE 1,603.00 Collection Number :17070481230000006789 dated 29-Mar-2024

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Subject to IMT Endorsement No. 24,25

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

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
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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 as amended from time to time.

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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
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
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RIGHT OF RECOVERY". For legal interpretation, English version will hold good.
UIN : IRDAN058RP0003V01201920
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Financier : SELF OWNED

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Previous Policy : TP/Ref. Pol No: 3194579115/000000/00 TP Expiry Date: 14/03/2027

37
00

OD Pol No: 3194579115/000000/00 OD Expiry Date: 14/03/2023

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TP/Ref. Insurer : TATA AIG

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OD Insurer : TATA AIG

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Nominee Name : Relation : Age :

431

Excess for Nil Depreciation Clause : 5% of claim amount subject to a minimum of Rs.250 and maximum of Rs.1000.
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In consideration of payment of additional premium as indicated in the Schedule it is hereby agreed and understood that indemnification in respect of Partial loss claims shall be done without application of
Depreciation as mentioned in Section 1. of the policy.
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NOTE : Warranted that in case of dishonour of the premium cheque, this document stands automatically cancelled 'AB-INITIO'.
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Policy stamp to be defaced at the respective policy servicing office.

Policy Details Cashless Garages Details

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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/9000167038 30/03/2024 12:07 AM

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