ORIGINAL FOR RECIPIENT/DUPLICATE FOR SUPPLIER.

TAX INVOICE/CERTIFICATE CUM POLICY SCHEDULE

(FORM 51 OF THE CENTRAL MOTOR VEHICLES RULES, 1989)
Policy Type Package Policy( Private Vehicle ) Proposal No. & Date R169935674 / 26-Jan-2023
Policy No. & Type 2311204486368901000 Period of Insurance 28-Jan-2023 to 27-Jan-2024
Policy Issued On 26-Jan-2023 (00:00) Vehicle Identification No. MA3EFJC1S00176081
Insured Name Mr. Rajnish Mahajan Geographical Area INDIA
Invoice No 2044863689010 Accounting Code of Service 997134
Insured Address S/O LATE SH. VIDYA SAGAR MAHAJAN, WARD NO. 8, NEAR GIRL SCHOOL NURPUR,DISTT: ,,, ,
KANGRA-176202, Himachal Pradesh
Insured State & Code Himachal Pradesh-02 Place of Supply Himachal Pradesh GSTIN of Customer GSTUNREGISTERED
INSURED MOTOR VEHICLE DETAILS INSURED DECLARED VALUE (IDV) (in Rs.)
Make Maruti Vehicle 125000
Model & Variant SX4-Vxi/MARUTI SX4 VXI (BSIV) Non Electrical Accessories 0
Registration No HP38B8289 Electrical Accessories 0
Year of Manufacture 2010 CNG/ LPG Kit 0
Engine- Chassis No 2036247 - MA3EFJC1S00176081 Total IDV 125000
Cubic Capacity 1586
Seating Capacity 5
Type Of Body Saloon
RTO Location HP38B8289 / NURPUR
Schedule Of Premium (Amount in Rs.)
OWN DAMAGE SECTION (A) LIABILITY SECTION (B)
Vehicle 764 Basic Third Party Liability 7897
Elec. Accessories 0 Third Party Liability for Bi-fuel Kit 0
Non- Elec. Accessories 0 Compulsory PA Cover Premium to Owner-Driver (1 Year) 325
Kit (IMT-25) 0 PA Cover for 5 Person of Rs (100000) each (IMT- 16 ) 250
Legal Liability (WC) to Driver (IMT-28) 50
Extra Premium towards Inbuilt CNG/LPG NA
Geographical Area Extn. (IMT-1) NA
Basic Premium 764 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) 8522
Fiber Glass Tank 0 Total Premium (A+B) 8944
CGST @9% 804.96
Sub-Total Additions 0
SGST @9% 804.96
Deductibles Gross Premium Paid 10554
Voluntary Deductibles (IMT 22A) 0
Anti-Theft Device (IMT-10) 19 MISP - PATHANKOT VEHICLEADES PVT LTD, NURPUR
AAI Membership (IMT-8) 0
No Claim Bonus (50%) 373 Notes :
Discount for vehicles designed for handicapped NA
1. Policy Issuance is the subject to the realisation of cheque.
Sub - Total Deductibles 392 2. Consolidate stamp duty paid to State Exchequer
Add - On Coverages 3. The Policy is subject to a compulsory Deductible of Rs 2000 (IMT -22)
4. Voluntary excess Rs (0)
ZERO DEPRECIATION 0 5. Subject to Endorsements IMT 10, 28, 16,
Engine & Gear Box Protector 0 6. UIN : IRDAN125RP0001V02201415
Return To Invoice 0 7. I/ We hereby certify that the policy to which the certificate relates as well as the certificate of insurance
are issued in accordance with the provision of Chapter X, XI of M. V. Act 1988." the stamp duty of Rs
Road Side Assistance 50 0.50 paid by the Demand Draft, vide receipt/ challan no. CSD/105/2021/2914 and dated 03/Aug/2021
Net own Damage Premium (A) 422 as prescribed in government of Maharastra order no Mudrank -2017/CR.97/M-1, dated the 09th
January 2018"
8. This policy provides the benefit of Roadside Assistance In case of emergency please contact on
below number: -

Contact No: - 02262346234

9. 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.

Nominee Details : Nominee Name SHALINI MAHAJAN Age 48 Relation Wife

Payment Method Cheque No./Transaction No. Bank Name Amount
Payment Detail
Electronic Payment 112777472583 ELECTRONIC PAYMENT 10554
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
2000(Compulsory Deductible Rs 2000 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 HDFC ERGO General 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:-A-60, Sarab Complex, Morning Site, Sanjauli, Shimla, (Formerly HDFC General Insurance Limited from September 14, 2016 and L&T General Insurance Company Limited up to September 13,
 2016)
GSTIN: 02AABCL5045N1ZK, CIN No.:U66030MH2007PLC177117
State Name : Himachal Pradesh