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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: [email protected]
GSTIN No: 27AAACN9967E1Z3

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RECEIPT

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Customer Details Collection Details

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Name : MISS. SUNITA YADAV Agent Code : 91067500000001

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Mobile No : 9451757429 Collection Number : 26020181235000442361
Email : [email protected] Collection Date : 27/12/2023

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Bank Account : 9100

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Received with thanks from Sri/Smt MISS. SUNITA YADAV

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a sum of 1241 (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
No. Year Number (General Ledger) Received

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44
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1 26020131236230446321 11 CASH PREMIUM A/C 5083 1052.00 0.00 1052.00

2 26020131236230446321 11
62 IGST_UP_Int_Liab 7399 189.00 0.00 189.00
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TOTAL : 1241.00 0.00 1241.00

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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

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 27/12/2023 10:33 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: [email protected]
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: 26020131236230446321 1 Year Package Policy from 00:00 Hrs of 30/12/2023 to Midnight of 29/12/2024 IXI

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Insured Details

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Name : MISS. SUNITA YADAV

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Mobile No : 9451757429 Email : [email protected]

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PAN No. : GSTIN No. :

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Channel : PHONEPE INSURANCE BROKING SERVICES PRIVATE LIMITED Tele. No: 080-68727888 Email : [email protected]

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Aadhar : PAN : xxxxxx058K Code. : 260201 / 91067500000001

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Vehicle Details

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Make & Model 2W HERO MAESTRO EDGE 110 DRUM BRAKE ALLOY WHEEL VX

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Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District

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UP-70-DM-9558 24381 04209 SCOOTER 111 2016 1+1 ALLAHABAD

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Geographical Area : INDIA.

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Registration Date : 03/10/2016

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Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV

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Rs.24,696 - - - - Rs.24,696

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OD Premium Breakup in Rs. TP Premium Breakup in Rs.

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Basic OD Premium 347.72 Basic TP Premium 714.00
(+) Geographical Area Extension - (+) Geographical Area Extension -
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(+) RSA Protect - (+) WC for Driver -
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(-) Auto. Assoc Discount - (+) PA to owner driver YES 295.00

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(-) Anti-theft Discount - (+) PA to unnamed PAX -

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(-) Other Discount - -260.79 (-) Discount For Limited TPPD -

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(-) NCB Discount 50% -43.46 TP Total (Rounded Off) 1,009.00

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(+) Nil Depreciation - OD Total (Rounded Off) 43.00

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(+) Nil Depreciation Plus - TOTAL PREMIUM 1,052.00

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(+) NCB Protect - GST 189.00

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(+) Engine Protect - NET PAYABLE 1,241.00

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(+) Invoice Protect - Collection Number :26020181235000442361 dated 27-Dec-2023

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OD Total (Rounded Off) 43.00 Subject to IMT Endorsement No. 16,22,22A,29

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

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,
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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
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
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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.

Limits of Liability Clause: Under section 1(i) Such amount as is necessary to meet the requirements of the motor vehicle act 1988.
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Under section 1(ii) Damage to third party property is Upto Rs. 1,00,000 . PA Cover under section 3 for owner-driver is Rs. 15,00,000.
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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
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.
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FINANCIER NAME :
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Prev Policy : HDFC Ergo General Insurance Company Ltd (Pol No: 2312910145227601000 Expiry Date: 01/10/2023)
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Nominee Name : YASHARTH YADAV Relation : Son Age : 21 Years

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Transaction Date : 27/12/2023 22:33:28 Transaction Number : VF2312272233216152441610 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'.
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
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including premium rate may be subject to change.

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
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For & On behalf of

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National Insurance Company Limited

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NIC/PHONEPE/91067500000001 27/12/2023 10:33 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: [email protected]
 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: [email protected]
GSTIN No: 27AAACN9967E1Z3

PROPOSAL FORM
PROPOSER'S DETAILS
Name MISS. SUNITA YADAV
Mobile No 9451757429 email id [email protected]

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Nominee's Name YASHARTH YADAV Relation Son Nominee's Age 21 Years

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VEHICLE DETAILS

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Model Two Wheeler HERO MAESTRO EDGE 110 DRUM BRAKE ALLOY WHEEL VX Year of Make 2016

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Reg No UP-70-DM-9558 Engine No 24381 Chassis No 04209

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Reg. Date 03/10/2016 Fuel PETROL

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Financier FastTag ID
IDV Rs. Rs.24,696

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Accessories Electrical Rs. - NIL Non-Electrical Rs. - NIL Bi-fuel Kit Rs. - NIL

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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 26020131236230446321

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Policy (period) from 00:00 Hrs of 30/12/2023 to Midnight of 29/12/2024

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CPA Owner/Driver YES

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Add-ons Included NOT OPTED

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PREMIUM DETAILS

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Total OD Premium Rs. 43.00 Total TP Premium Rs. 1,009.00 GST Rs. 189.00 Premium Payable Rs. 1,241.00

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PREVIOUS POLICY DETAILS *
Previous Policy Type PACKAGE Previous Policy Expiring on :00 01/10/2023
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Previous Policy No 2312910145227601000 issued by HDFC Ergo General Insurance Company Ltd
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Previous NCB % 50 Claims reported in Previous Policy No

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
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.

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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.
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
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
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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
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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
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.
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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 : 27/12/2023
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This Proposal form has been electronically accepted

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NIC/PHONEPE/ 91067500000001 27/12/2023 10:33 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: [email protected]