ORIGINAL FOR RECIPIENT/DUPLICATE FOR SUPPLIER.

TAX INVOICE/CERTIFICATE CUM POLICY SCHEDULE B

(FORM 51 OF THE CENTRALMOTOR VEHICLES RULES, 1989)
Policy Type Package Policy( Private Vehicle ) Proposal No. & Date R195427067 / 04-Jul-2024
Policy No. & Type 2372/74261617/00/000 Period of Insurance 04-Jul-2024 03:42:13:PM to 03-Jul-2025
Policy Issued On 04-Jul-2024 (00:00) Vehicle Identification No. MB8DP11AEH8428957
Insured Name Mr. Rahul Gupta Geographical Area INDIA
Invoice No 19MI240060365 Accounting Code of Service 997134
Insured Address 8/1,KIRTY BASH MUKHERJEE ROAD,MUCHI BAZAR DASPARAPO+PS-ULTADANGA, jaishwal club,,,,
KOLKATA-700067, West Bengal
Insured State & Code West Bengal-19 Place of Supply West Bengal GSTIN of Customer GSTUNREGISTERED
INSURED MOTOR VEHICLE DETAILS INSURED DECLARED VALUE (IDV) (in Rs.)
Make Suzuki Vehicle 25879
Model & Variant ACCESS-125/ACCESS Non Electrical Accessories 0
Registration No WB08D4630 Electrical Accessories 0
Year of Manufacture 2017 CNG/ LPG Kit 0
Engine- Chassis No AF211322064 - MB8DP11AEH8428957 Total IDV 25879
Cubic Capacity 124
Seating Capacity 2
Type Of Body Solo With Pillion
RTO Location WB08D4630 / KOLKATA
Schedule Of Premium (Amount in Rs.)
OWN DAMAGE SECTION (A) LIABILITY SECTION (B)
Vehicle 353 Basic Third Party Liability 714
Elec. Accessories 0 Third Party Liability for Bi-fuel Kit 0
Non- Elec. Accessories 0 Compulsory PACover Premium to Owner-Driver (1 Year) 225
PACover for 0 Person of Rs (0) each (IMT- 16 )
Kit (IMT-25) 0
Legal Liability (WC) to Driver (IMT-28) 0
Extra Premium towards Inbuilt CNG/LPG NA Geographical Area Extn. (IMT-1) NA
Basic Premium 353 Legal Liability to Employees (IMT-29) 0
Geographical Area Extn. (IMT-1) NA Legal Liability to Passenger (IMT 46) 0
Lamp, Tyres etc. (IMT 23) 0 Driving Tuition Loading On TP Premium (60%) NA
Net Liability Premium (B) 939
Driving Tuition Loading On OD Premium (60%) NA
Total Premium (A+B) 1115
Fiber Glass Tank 0 CGST @9% 100.35
Sub-Total Additions 0 SGST @9% 100.35
Deductibles Gross Premium Paid 1316
Voluntary Deductibles (IMT 22A) 0 MISP - Mondal Motors LLP, KOLKATA
Anti-Theft Device (IMT-10) 0
AAI Membership (IMT-8) 0
Notes :
No Claim Bonus (50%) 177
Discount for vehicles designed for handicapped NA 1. Policy Issuance is the subject to the realisation of cheque.
2. Consolidate stamp duty paid to State Exchequer
Sub - Total Deductibles 177 3. The Policy is subject to a compulsory Deductible of Rs 100 (IMT -22)
Add - On Coverages 4. Voluntary excess Rs (0)
5. Subject to Endorsements IMT
Depreciation Waiver 0 6. Policy has been issued subject to valid Pollution Under Control (PUC) Certificate declared by you as
Engine Protector 0 an insured on or before the date of commencement of the Policy
7. OD Premium rates are different for NCB/Non-NCB class of customer. In case of change from NCB to
Return To Invoice 0 Non-NCB, the recoverable amount may be more than the NCB amount.
Net own Damage Premium (A) 176
Nominee Details : Nominee Name RAM KUMAR GUPTA Age 51 Relation Father
Payment Method Cheque No./Transaction No. Bank Name Amount
Payment Detail
Electronic Payment 113359970054 ELECTRONIC PAYMENT 1316
Financier Type Not Financed Financier Name NA Financier Branch NA
LIMITATIONS AS TO USE : The Policy covers use of the vehicle for any purpose other than: (1) Hire or Reward (2) Carriage of goods (other than samples or personal luggage (3) Organized racing (4) Pace making (5)
Speed testing (6) Reliability Trials (7) Any purpose in connection with Motor Trade.
DRIVER : Any person including 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 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. 100000 - (as per IMT 20) in respect of any one claim or series of claims arising out of one event. Cover for Owner - Driver under section III (CSI) Rs. 1500000 Lakh
Deductible under section -I : Rs 100 (Compulsory Deductible Rs 100 Imposed Deductible Rs 0 and Voluntary Deductible Rs, 0)
No Claim Bonus: The insured is entitled for a No Claim Bonus (NCB) on the Own Damage section of the policy, if no claim is made or pending during the preceding year (s), as per the: The preceding year/20%,
Preceding Two consecutive years/25%, Preceding Three consecutive years/35%, Preceding Four consecutive years/45%, Preceding Five consecutive years/50% of NCB on OD Premium. No Claim Bonus will only be
allowed provided the policy is renewed within 90 days of the expiry date of the previous policy.
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 reason of wider terms 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 RIGHT OF RECOVERY"
For information on ombudsman you may visit website https://www.cioins.co.in/Ombudsman
I / We hereby certify that the Policy to which this Certificate relates as well as this Certificate of Insurance are issued in accordance with the provisions of Chapter X and Chapter XI of M.V. Act, 1988.
For Universal Sompo General Insurance Co. Ltd

Authorized Signatory
Policy Issuing Office:-7th Floor,Express Towers, 42A,Shakespeare Sarani,Kolkata - 700017.
GSTIN: 19AAACU8917F1Z3, CIN No.:U66010MH2007PLC166770
State Name : West Bengal