s KARNATAKA STATE
CERTIFICATE OF REGISTRATION
TRANSPORT DE PARTMENIT
REGNO: KA04MXO531 FORM-23A
(See Rule 49
REG.DATTE :0811/2019 o.SLNO : 01
CHASSISNO :MAT627265KLJ36535 COLOUR: CALGARY_WHTE
ENGINENO REVTRN03JPYKT73841 CLASS: Motor Car
MFR TATA MOTORS LTD
OWNERNAME: SUVARNAMMA H M
SWD OF MAHALINGAPPA HV
ADDRESS : 53 BASAVASAMITHI LO NEAR
ESHWARA TEMPLE THINDLU
VIDYARANYAPURA Banga lore KA560097
MODEL TATA NEXON- XZA+ 1.2 RTN BS4
BODY : SALOON NO.OF CYL 03
WHEEL BASE: 0024s8 UNLADEN WT 00122
MFG.DATE 09/2019 SEATING :005
FUEL PETROL STDG/SLPR 00
REGFC UPTO: 0711/2034 CC 00119
TAX UPTO LTT Registering Authortty
Bengaluru{N
COMPUTERISED POLLUTION UNDI
(Rule
c.
231 (B)(8)
8)(8) of MV Rules 1989)
meets Emission
Standards Prescribed by Rul 115(2)
19
of MVR
This Vehicle Months for Bharat Stage I1I or below dnd one year for Bharat Stace t e is All India valid, S i
LicenceN o : 996/2009-10 Photo of Vehicle
Matha Emission Testing
Center Name Center
36, Pattanagere, Mysore
rd, Near RTO, Bangalore-
Center Address:
Customer Name
59
KAOLHXO531
Customer Mobile: 9448379227
Pucc No P558KA105527
Vehicle No: KA04MX0531
Year of Regn: 04-11-2019
Type of Vehicle: 4 Wheeler Petrol Test Gas Test
Type of Engine: 4 STROKE Pres Measured Pres Measured
Make: Tata Motors STD level STD level
Unit
Model: Nexon co 0.5 00.026
Fuel: PETROL
HC 750 00045 PPM
Catalyst : Catalyst
ESIO Test Date04-11-2020 17:23 co2
02
05.68
12.40
a l i d Date : 03-05-2021
BANGALORE Hologra Certificate price: s 0
Certificate is not acceptable without Hologram Sticker
& Get Renewed the Certificate within the Expin Das
Testing Station Code (P5ss) Authoriss Synatoy
Seal of Testing Station
CERTIFICATE & NOT HAND OVER TO ETC IN ANY CIRCUMSTANCES
uqrerDav THE o d DO
Liberty (ieneral suruneu
Liberty Servicing O/flce of nsurer: OTICE NUMII:R 1, AL.YSSA IIRST
NUMB:R 28, NETY NUMBER, 21, RICUMON) FIA0OR,EAN
General Insurnnue.
(State ule:29) 5o0025, PI-0 NOO 200 ROAD, WANGALORE MD23, PONTION.OLL
PAN: AABCL9950A GSTIN: 29AAHCT9950ATZ1 www.libertyinsuranee.nHumgalore, kKun
.
5N44 Wobwiter ar nataku
Unsurer's RDA
Tollliee llelpline 1800-200-$844 Iuil: Reginlration Number: 10
U6600OMI2010PLC209656 branejuoperationsgylibertyinmuane.in CIN
STAND-ALONE OWN DAMAGE POIICY POR
IRDANI50RP000IVO1201920) CUM RECEPT PRIVATE CAR (UIN
oD Policy No. 2025500201208002213O1000
Insured Name MRS. SUVARNAMMA IIM Polley Inued (On (04
Own Damage Period 07-NOV-2020(00:00) To
NOV-2020 (12.35)
06-NOV-2021 (Midnight)
Motur Lulility Period
Proposal No. & Date
PPVBU9556893, 04-NOV-2020 Motor ability
Poliey No 07-NOV-2919000:00) To 0-NOV-22AMisnigha)
Insured Add. NO 53,
S60097
BASAVASAMITIII LAYOUT, NEAR ESIWAI
20115)20119HK31519I9) (1S)
Previous Insurer TEMPLE THINDILU,
LGI
VIDYARANYAP BENGALURU ,
Prevlous Polley No.
2011 KARNATAKA
(Mate Ck1)
IRDA Lic. No.: 375, CIN No.:
Name &Add.: TATA MOTORSU50300OMH19971PLCI49349
Broker Detalils 50020119006315000) 7-NOV-2019 To NOv-22
ANDHERI (EAST), INSURANCE BROKING AND
MUMBAI 400 059, INDIA ADVISORY SERVIC:S
Broker Cutegory: (Composite Hroker,
Validity: 13-MAY-20
LTD, IST FLOOR, AFI To 12-MAY-23
HOUSE, IOK
Make
Model BJIARATI COMPLEX, MAKOL
TATA MOTORS Sub Model MARSHI POA
NEXON Cuble Cupncity
Body Type
NEXON (P) XZA+
(ST) Manulacturing Year
Registration No. 19% Seatíng capacity
RTO 2919
COMPACT SUV KA 04 MX 0531 Involce Dute
YESWANTHAPURA ngine No.
Vehicle IDv 31-0CT-2019 Chassis No.
CNG/LPG Ri Elec. Acceusorle KEVTRNO3JPYK73A1
900,000 Non-Elec. Acvessuries Tutas IDv
MAT627265KLI6535
Own Damage Premium (A) Schedule of 900,000
Prenlum (Amount in IRs.)
Basic Premium
Vehicle
Non-Elcc. Accessorics Deductibles
10,342 Voluntary Deductibles (0)
Elec. Accessories (IMT-24) 0 Anti Thcst Devicc (IMT-22A)
CNG/LPG Kit (IMT-25) (IMT-10)
0 AA Membership (IMT-8)
Sub Total
(BasicPremium) 0 No Claim Bonux
(20%)
Geographical Area Extension (IMT-1) 10,342 Hundicapped Discount (0%)
IMT 23 Premium
Sub Total (Deductibles)
2.069
Add On Coverages (Rcfer Note
5) 2.069
Sub Total-Addition 9320|
Nute: I.Warning that in
19662| Net Own
Damage Premium (A)
case of dishonour of the
automatically caucelled 'ab-initiu premium cheque, this ducument stunds 17593
2.Consolidated stamp duty puid to state Total Premium (A)
3.The exchequer.
policy is subject to compulsory deductible | CGST (9%)
of Rs.1000 (IMT-22) 17593
dd-on: Add on Plan
ear:300,Nil 3(Consumables-I Year:1620,Fngine Proteet-I SGST (9% I584
5.The Depreciation-1 Yeur:1800,Kuy Replucemcnts-
insurance compuny willYcar:5400,Personal Belonging-1 Yeur:200)
an displuy terms & conditions on its webwite
1584
be accesscd by you online. www.libcrtyinaurunco.in which
Subject to IMT Endt. Nos.&
Memorandum:7.22
yment Details : Cheque No.; |Q2006611700 C | Cross Prsmiun Puil
