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Servicing Office Address
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Mandi Dabwali Business Office,B.O.DABWALI Arora ComplexChautala,
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Dabwali Sirsa
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GSTIN No: 06AAACN9967E2Z6
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RECEIPT
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Customer Details Collection Details
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Name : Mr SANJAY Agent Code : 91066900000001
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Address : S/O KARAN SINGH PREM NAGAR NARWANA Collection Number : 42070381248000008340
JIND HR , HARYANA , NARWANA Collection Date : 21/03/2025
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Pin Code : 126116 Bank Account : 9151
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Received with thanks from Sri/Smt Mr SANJAY
a sum of 842 (RUPEES EIGHT HUNDRED FORTY TWO ONLY) by ONLINE
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towards 1 Year Liability Only 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
26
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1 42070331246760005526 11 CASH PREMIUM A/C 5083 714.00 0.00 714.00
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2 42070331246760005526 11 CGST_HR_Int_Liab 7337 64.00 0.00 64.00
60
67
3 42070331246760005526 11 SGST_HR_Int_Liab 7338 64.00 0.00 64.00
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TOTAL : 842.00 0.00 842.00
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Particulars : ONLINE
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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
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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
in terms of the provisions of the said sub-rule.
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Authorised Signatory
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NIC/UBPORTAL/91066900000098 12/06/2025 05:26 PM
Visit us at https://nationalinsurance.nic.co.in for information on Products, Services and Grievance Redressal.
-1-
Issuing Office Name & Address
MANDI DABWALI BUSINESS OFFICE , B.O.DABWALI ARORA COMPLEXCHAUTALA,
DABWALI SIRSA
Tel: 01668 222776 (G) , 229076 Fax:
GSTIN No: 06AAACN9967E2Z6
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 as amended from time to time
Policy No: 42070331246760005526 2W 1 Year Liability Only from 13:01 Hrs of 21/03/2025 to Midnight of 20/03/2026 IXI
Insured Details
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Name : Mr SANJAY
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Address : S/O KARAN SINGH PREM NAGAR NARWANA JIND HR , HARYANA , NARWANA
3/2
Pincode : 126116 Telephone : xxxxxxxx88 Email : [email protected]
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PAN No. : GSTIN No. : Aadhar No. : xxxx xxxx 6343
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Channel : WHITE HORSE INSURANCE BROKER P Mobile : 7861969699 Email : [email protected]
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Aadhar : PAN : xxxxxx642F Code. : 420703 / 91066900000001
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Vehicle Details
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Make & Model Two Wheeler HF DELUXE DRUM SELF ALLOY BLACK
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Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District
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HR-32-L-3575 J11577 J11645 STREET 97 2019 1+1 JIND
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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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- - - - - -
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OD Premium Breakup in Rs. TP Premium Breakup in Rs.
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Basic OD Premium Basic TP Premium 714.00
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(+) Geographical Area Extension - (+) Geographical Area Extension :21 -
(-) Vol. Excess Discount - (+) WC for Driver -
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(-) Auto. Assoc Discount - (+) PA to owner driver -
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(-) Anti-theft Discount - (+) PA to unnamed PAX -
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(-) Other Discount - (-) Discount For Limited As per MV Act -
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(-) NCB Discount TP Total (Rounded Off) 714.00
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(+) Nil Depreciation - OD Total (Rounded Off)
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(+) Nil Depreciation Plus - TOTAL PREMIUM 714.00
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(+) NCB Protect - GST 128.00
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(+) Engine Protect - NET PAYABLE 842.00
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(+) Invoice Protect - Collection Number :42070381248000008340 dated 21-Mar-2025
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OD Total (Rounded Off) Subject to IMT Endorsement No. 24,25
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Excess : Compulsory: Rs. 0 Imposed: Rs. 0 Voluntary: Rs. 0
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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
making (e) Speed Testing and Reliability Trials (f) Use in connection with Motor Trade
5
05
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
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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Limits of Liability Clause: Under section 1(i) Such amount as is necessary to meet the requirements of the motor vehicle act 1988.
Under section 1(ii) Damage to third party property is Upto Rs. 1,00,000 .
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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 reasons of wider terms
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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 OF RECOVERY". For legal interpretation, English version will hold good.
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UIN : IRDAN058P0036V01100001
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Financier : SELF OWNED
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Prev Policy : Not Available
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Nominee Name : Relation : Age :
No
NOTE : Warranted that in case of dishonour of the premium cheque, this document stands automatically cancelled 'AB-INITIO'.
Policy stamp to be defaced at the respective policy servicing office.
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TP Rate Revision Notice: For all policies having an effective date on or after 1st April 2023, the TP premium is subject to revision as may be notified by the IRDAI.
The Insured should contact and submit the difference of premium to the policy issuing office on issuance of such notification by IRDAI.
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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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Policy 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/91066900000098 12/06/2025 05:26 PM
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]
