ORIGINAL FOR RECIPIENT/DUPLICATE FOR SUPPLIER.

TAX INVOICE/CERTIFICATE CUM POLICY SCHEDULE

(FORM 51 OF THE CENTRALMOTOR VEHICLES RULES, 1989)
Policy Type Package Policy( Private Vehicle ) Proposal No. & Date R74802542 / 23-Nov-2018
Policy No. & Type 3001/MI-06639331/00/000 Period of Insurance 00:00:00 AM 05-Jan-2019 to midnight on 04-Jan-2020
Policy Issued On 23-Nov-2018 (00:00) Vehicle Identification No. MA3FXEB1S00185476
Insured Name Mr. Akansha Ashok Kandoi Geographical Area INDIA
Invoice No 181118618638 Accounting Code of Service 997134
Insured Address B-109, SINDHU SAGAR MHATMAPHULE RAOD VISHUNAGAR,DOMBIVALI (W), Near Dhyansawar Mangal Karalaya, dhaynewar mangle karalay,
KALYAN-421201, Maharashtra
Insured State & Code Maharashtra-27 Place of Supply Maharashtra GSTIN of Customer GSTUNREGISTERED
INSURED MOTOR VEHICLE DETAILS INSURED DECLARED VALUE (IDV) (in Rs.)
Make Maruti Vehicle 600000
Model & Variant CIAZ Smart Hybrid ZDI/MARUTI CIAZ SHVS ZDI Non Electrical Accessories 0
Registration No MH05CM6823 Electrical Accessories 0
Year of Manufacture 2015 CNG/ LPG Kit 0
Engine- Chassis No 2725398 - 185476 Total IDV 600000
Cubic Capacity 1248
Seating Capacity 5
Type Of Body Saloon
RTO Location MH05CM6823 / KALYAN
Schedule Of Premium (Amount in Rs.)
OWN DAMAGE SECTION (A) LIABILITY SECTION (B)
Vehicle 8616 Basic Third Party Liability 2863
Elec. Accessories 0 Third Party Liability for Bi-fuel Kit 0
Non- Elec. Accessories 0 Compulsory PACover Premium [1 Year] 750
Kit (IMT-25) 0 PACover for 5 Person of Rs (50000) each (IMT- 16 ) 125
Extra Premium towards Inbuilt CNG/LPG NA Legal Liability (WC) to Driver (IMT-28) 50
Basic Premium 8616 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
Driving Tuition Loading On OD Premium (60%) NA Net Liability Premium (B) 3788
Fiber Glass Tank 0 Total Premium (A+B) 14649
Sub-Total Additions 0 CGST @9% 1318
Deductibles SGST @9% 1318
Voluntary Deductibles (IMT 22A) 0 Gross Premium Paid 17285
Anti-Theft Device (IMT-10) 215 Note :
AAI Membership (IMT-8) 0
No Claim Bonus (35%) 2940 1. Policy Issuance is the subject to the realisation of cheque.
2. Consolidate stamp duty paid to State Exchequer
Discount for vehicles designed for handicapped NA 3. The Policy is subject to a compulsory Deductible of Rs 1000 (IMT -22)
Sub - Total Deductibles 3155 4. Voluntary excess Rs (0)
Add - On Coverages 5. Subject to Endorsements IMT 10, 28, 16,
Zero Depreciation 5400 6. UIN : IRDAN115P0017V01200102
Engine Protect 0
Return to Invoice 0
Net own Damage Premium (A) 10861
Nominee Details : Nominee Name VARSHAKANDOI Age 48 Relation Mother
Payment Method Cheque No./Transaction No. Bank Name Amount
Payment Detail
Net Banking 107475398792 ELECTRONIC PAYMENT 17285
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: 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.
Limits of Liability: Under Section II-1 (i) of the policy - Death of or bodily injury - Such amount as is necessary to meet there requirements of the Motor Vehicles Act, 1988. Under Section II -1(ii) of the Policy - Damage to
Third Party Property - Rs.7.5 lakhs - (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 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 : http://www.gbic.co.in/ombudsman.html
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 ICICI LOMBARD GENERAL INSURANCE CO LTD.

Authorized Signatory

Policy Issuing Office:-Ground, First , Second and Third ICICI Lombard House Veer Sawarkar Marg Mumbai-Prabhadevi Maharashtra 400025
GSTIN: 27AAACI7904G1ZN, CIN No.:U67200MH2000PLC129408
State Name : Maharashtra