Service Branch Address: No.4B, 4th Floor, "" A"" Block, Mena Kampala Arcade,Sir Theyagaraya Road, T.Nagar.

December 01, 2022

. Intermediary Code: BR500210

Mr.. RAMFCDSF F SUNDRA
FDSG FDS Intermediary Name: POLICY MASTER
FDSF FDSF INSURANCE
JANJGIR CHAMPA,
700021
BROKERS PRIVATE
Telephone : LIMITED
Mobile : xxxxxx8957
Contact: 1141221222
CERTIFICATE OF INSURANCE & POLICY SCHEDULE
(See Form 51 of The Central Motor Vehicles Rules, 1989) Motor Vehicles Act, 1988
1 Year Two Wheeler Policy – Liability only
Policy Period: Period Of Insurance
Certificate of Insurance and Policy No.
VMLI215985000100 From 00:00:00 hours on 02/12/2022 To 23:59:59 hours on 01/12/2023
INSURED DETAILS
Insured Date Geographical Registration Registration
Name of Insured Business/Profession
of Birth Area Authority Date
Mr.. RAMFCDSF F SUNDRA 30/11/2004 India RANCHI 01/02/2017
The Vehicle: any of the following (Two-wheeler shall be deemed to include a sidecar attached to it)
VEHICLE DETAILS
FLASH 48V/28AH - 2
Registration Number JH-01-BV2764- Model Description
SEATER
Engine Number FDSF477DSF Type of Body ELECTRIC SCOOTER
Chassis Number FDSF7447D8SF Cubic Capacity 0
Make of the Vehicle HERO ELECTRIC Year of Manufacture 2017
Seating Capacity 2 Total Premium(in Rs.) 539.26
DRIVER: Any person including the Insured:• Provided that a person driving holds an
LIMITATIONS AS TO USE:The Policy covers use of the vehicle for any purpose
effective driving license at the time of the accident and is not disqualified from holding or
other than: a) Hire or Reward b) Tution c) Carriage of goods (other than samples or
obtaining such a license. • Provided also that the person holding an effective Learner’s
personal luggage) d) Organised racing e) Pace making f) Speed testing g) Reliability
License may also drive the vehicle and that such a person satisfies the requirements of
Trials h) Any purpose in connection with Motor Trade
Rule 3 of The Central Motor Vehicles Rules, 1989.
LIMITS OF LIABILITY:Under Section II-1 (i) of the Policy - Death of or bodily injury - Such amount as is necessary to meet the requirements of the Motor Vehicles Act, 1988. Under Section II-1 (ii) of the
Policy -Damage to Third Party Property - Rs Rs.1,00,000Personal Accident cover for Owner - Driver under section III: CSI Rs. 15,00,000.00

Nominee Name : Nominee Age : Relationship with :

Guardian Name : Guardian Age : Guardian Relation :
LIABILITY
1. Basic premium including premium for TPPD 457.00
2. Less: TPPD restricted to statutory limit of Rs.6000/- (Endt. IMT. 20) 0.00
3. Bi-fuel kit (CNG/LPG) 0
Add:
4. PA to Paid Driver CSI Rs. (IMT 17)
0.00
Number of Persons-1
5. Geographical Area Extn.Endt.IMT-1 0.00
6. PA cover for Owner - Driver under Section III CSI Rs. 15,00,000.00 0.00
7. PA to Unnamed Passengers (IMT 16) 0.00
8. Enhanced PA for Unnamed Passengers, CSI Rs. 0 0.00
9. Enhanced PA for Owner Driver, CSI Rs. 0 0.00
10. Enhanced PA for Paid Driver, CSI Rs. 0 0.00
Legal Liability ADD: IGST
82.26
11. Legal Liability To Paid Driver (IMT 28) 0.00
12. Legal Liability To Employees (IMT 29) 0.00 Signature Not
TOTAL LIABILITY PREMIUM (B) 457.00 Verified 539.26
Subject to IMT Endt. Nos. & memorandum 22 (refer Terms & Conditions for relevant wording) Digitally signed by
TAIKAD MAHADEVAN
In Witness whereof this Policy has been signed at Chennai on in lieu of Cover note No. dated Receipt No. .Subject to IMT Endt. Nos & Memorandum . I/We hereby certify that the Policy to which this
SHYAMSUNDER
Certificate relates as well as this Certificate of Insurance are issued in accordance with the provisions of Chapter X and Chapter XI of the Motor Vehicles Act, 1988. Date: 2022.12.01
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 12:37:44
by reason GMT+05:30
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 Reason: For
OF RECOVERY" under Policy
RoyalSundaram
Terms and Conditions. Location: Chennai
For Royal Sundaram General Insurance Co. Limited

Authorised Signatory
Consolidated Stamp Duty Paid to Govt of TamilNadu This document is digitally signed, hence counter signature / stamp is not required.
For Legal interpretation, English version will hold good. ServiceTaxNo: AABCR7106GST001 UIN: PAN Number : AABCR7106G

Document Code:
Fastag ID:
 GST Invoice
Royal Sundaram General Insurance Co. Limited
Millenium City Information Technology Park
Unit No T-2-2A,Tower 2Plot No : DN-62,Sector -V, Salt Lake
Kolkata - 700 091
GSTIN : 19AABCR7106G1ZG

Policy Number : VMLI215985000100

GST Invoice Number : VMLI21598500000
Inception Date : 02/12/2022 12:00:00
Policy Posted Date : 01/12/2022 12:37:44

Address of insured:
FDSG FDS
FDSF FDSF
JANJGIR CHAMPA
State:Chattisgarh
Pincode: 700021

Accounting code of service : 997134

Description of service: Motor vehicle insurance services

Taxable premium 457.00

Add: IGST 18% 82.26

Gross Premium 539.26

Indication if tax payable under reverse charge - No

"I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover
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.":’

Note: “This document is digitally signed.