ORIGINAL FOR RECIPIENT/DUPLICATE FOR SUPPLIER.

TAX INVOICE/CERTIFICATE CUM POLICY SCHEDULE

(FORM 51 OF THE CENTRALMOTOR VEHICLES RULES, 1989)
Policy Type Stand-alone OD Policy ( Private Vehicle ) Proposal No. & Date SR19896544 / 10-Sep-2024
Policy No. & Type 39070031241850507514 Period of Insurance 15-Sep-2024 to 14-Sep-2025
Policy Issued On 10-Sep-2024 (00:00) Vehicle Identification No. MA3JMTB1SPD887788
Insured Name Mrs. Sakshi Devi Geographical Area INDIA
Invoice No 4131248622198 Accounting Code of Service 997134
Insured Address Bashariya DISTT-GURUGRAM GURGAON ,
GURGAON-122503, Haryana
Insured State & Code Haryana-06 Place of Supply Haryana GSTIN of Customer GSTUNREGISTERED
INSURED MOTOR VEHICLE DETAILS INSURED DECLARED VALUE (IDV) (in Rs.)
Make Maruti Vehicle 515600
Model & Variant MARUTI WAGON R LXI CNG 1L 5MT BS6/MARUTI WAGON R LXI CNG 1L 5MT BS6 Non Electrical Accessories 2832
Registration No HR26FE1987 Electrical Accessories 6552
Year of Manufacture 2023 CNG/ LPG Kit 0
Engine- Chassis No C309442 - MA3JMTB1SPD887788 Total IDV 524984
Cubic Capacity 998
Seating Capacity 5
Type Of Body Saloon
RTO Location HR26FE1987 / GURGAON
Schedule Of Premium (Amount in Rs.)
OWN DAMAGE SECTION (A) Pre-Existing Third Party Policy Details.
Vehicle 2666 Insurance Company Name UNITED INDIAINSURANCE COMPANY LIMITED
Elec. Accessories 262 Policy No. 04280031230160231117
1. MSIL/CENTRE LOCK of value Rs. 6552 Risk Inception Date 15-Sep-2023
Non- Elec. Accessories
1. MSIL/WHEEL COVER MUD FLAP of value Rs. 1640 15 Risk Expiry Date 14-Sep-2026
2. MSIL/DOOR VISOR of value Rs. 1192
Kit (IMT-25) 0 MISP - Platinum Motocorp LLP, MANESAR
Extra Premium towards Inbuilt CNG/LPG 133
Basic Premium 2943
Geographical Area Extn. (IMT-1) NA Notes : ( For Stand-alone OD Policy )
Lamp, Tyres etc. (IMT 23) 0 1. Policy Issuance is the subject to the realisation of cheque.
Driving Tuition Loading On OD Premium (60%) NA 2. Consolidate stamp duty paid to State Exchequer
Fiber Glass Tank 0 3. The Policy is subject to a compulsory Deductible of Rs 1000 (IMT -22)
Sub-Total Additions 0 4. Voluntary excess Rs (0)
Deductibles 5. Subject to Endorsements IMT ,7 10,
Voluntary Deductibles (IMT 22A) 0 6. The Coverage under this policy is only for Own Damage and no other liability in connection with
Anti-Theft Device (IMT-10) 74 the vehicle.
AAI Membership (IMT-8) 0 7. OD Premium rates are different for NCB/Non-NCB class of customer. In case of change from NCB to
Non-NCB, the recoverable amount may be more than the NCB amount.
No Claim Bonus (20%) 574
Discount for vehicles designed for handicapped NA
Sub - Total Deductibles 648
Add - On Coverages
Nil Depreciation Plus 3150
Engine Protect 0
Invoice Protect 0
Consumables Protect 630
Net own Damage Premium (A) 6208
CGST@9% 558.72
SGST@9% 558.72
Total OD Premium 7325
Nominee Details : Nominee Name VINOD KUMAR SINGH Age 37 Relation Husband
Payment Method Cheque No./Transaction No. Bank Name Amount
Payment Detail
MasterCard Credit Card 113455699137 ELECTRONIC PAYMENT 7325
Financier Type Financed Financier Name KOTAK MAHINDRAPRIME LTD Financier Branch GURGAON
Limitations 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, f) Reliability Trials, g) Any purpose in connection with Motor Trade.
Driver: 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 Motor Vehicles Rules, 1989.
Deductibles: Deductible under section-I : Rs 1000(Compulsory Deductible Rs 1000 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 following: The preceding year/20%,
Preceding Two consecutive years/25%, Preceding Three consecutive years/35%, Preceding Four consecutive years/45%, Preceding Five consecutive years/50%. 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 Legal interpretation, English
version will hold good.
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 National Insurance Company Limited
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.
Authorized Signatory
Policy Issuing Office:-Gurgaon Divisional Office III, 407, D L F Qutab Plaza, Phase IGurgaon
GSTIN: 06AAACN9967E2Z6, CIN No.:U10200WB1906GOI001713
State Name : Haryana