TAX INVOICE e-Invoice

IRN : a02b6c5b27a74c89f1f929837080679aa54f29f3b290e3-
bf05aa524bc188de1c
Ack No. : 162418771464261
Ack Date : 30-Oct-24

Dilsan Tyre Works Invoice No. e-Way Bill No. Dated

Plot No. 34 to 35A, TAX/2024-25/0148 631806966593 30-Oct-24
Railway Crossing, Delivery Note
Airport Ring Road,
Nr. Manglam Residency, Dispatch Doc No. Delivery Note Date
Bhuj-Kutch -370001
GSTIN/UIN: 24ABPPI7542D1ZP Dispatched through Destination
State Name : Gujarat, Code : 24
Buyer (Bill to) By Road
Bill of Lading/LR-RR No. Motor Vehicle No.
Boss Rubber Reclaim Private Limited
SURVEY NO 76 dt. 30-Oct-24 GJ03BT4272
CHACHAVADARDA
MORBI
GSTIN/UIN : 24AAFCB7305K1ZR
State Name : Gujarat, Code : 24
Sl Description of Goods HSN/SAC Quantity Rate per Amount
No.
1 Used Rubber Scrap (Kgs) 40040000 6,110.000 Kgs 12.00 Kgs 73,320.00

CGST 1,833.00
SGST 1,833.00

Total 6,110.000 Kgs ₹ 76,986.00

Amount Chargeable (in words) E. & O.E
INR Seventy Six Thousand Nine Hundred Eighty Six Only
HSN/SAC Taxable CGST SGST/UTGST Total
Value Rate Amount Rate Amount Tax Amount
40040000 73,320.00 2.50% 1,833.00 2.50% 1,833.00 3,666.00
Total 73,320.00 1,833.00 1,833.00 3,666.00
Tax Amount (in words) : INR Three Thousand Six Hundred Sixty Six Only
Company's Bank Details
Bank Name : Icici Bank A/c 348705500590
A/c No. : 348705500590
Company's PAN : ABPPI7542D Branch & IFS Code: Atmaram Circle & ICIC0003487
Declaration for Dilsan Tyre Works
We declare that this invoice shows the actual price of the
goods described and that all particulars are true and
correct. Authorised Signatory
SUBJECT TO BHUJ JURISDICTION
This is a Computer Generated Invoice
 e-Way Bill e-Way Bill

Doc No. : Tax Invoice - TAX/2024-25/0148

Date : 30-Oct-24

IRN : a02b6c5b27a74c89f1f929837080679aa54f29f3b290e3bf05aa524bc188de1c
Ack No. : 162418771464261
Ack Date : 30-Oct-24

1. e-Way Bill Details

e-Way Bill No. : 631806966593 Mode : 1 - Road Generated Date : 30-Oct-24 11:30 AM
Generated By : 24ABPPI7542D1ZP Approx Distance : Valid Upto : 1-Nov-24 11:59 PM
Supply Type : Outward-Supply Transaction Type: Regular

2. Address Details
From To
Dilsan Tyre Works Boss Rubber Reclaim Private Limited
GSTIN : 24ABPPI7542D1ZP GSTIN : 24AAFCB7305K1ZR
Gujarat Gujarat

Dispatch From Ship To

Plot No. 34 to 35A,, Railway Crossing,, Airport Ring Road,, SURVEY NO 76, CHACHAVADARDA, MORBI MORBI
Nr. Manglam Residency,, Bhuj-Kutch -370001 Gujarat Gujarat 363641
Gujarat 370001

3. Goods Details

HSN Product Name & Desc Quantity Taxable Amt Tax Rate
Code (C+S)

40040000 Used Rubber Scrap (Kgs) & Rubber Scrap 6,110 KGS 73,320.00 2.50+2.50

Tot.Taxable Amt : 73,320.00 Other Amt : Total Inv Amt : 76,986.00

CGST Amt : 1,833.00 SGST Amt : 1,833.00

4. Transportation Details
Transporter ID : Doc No. :
Name : Date : 30-Oct-24

5. Vehicle Details
Vehicle No. : GJ03BT4272 From : Gujarat CEWB No. :
 0
1 1
Product Code: 3003 UIN: IRDAN115RP0013V01200203

Reference No.: W358796440

Date: Oct 14, 2024
RAGHUBHAI PANCHABHAI RATADIYA
AT RAMNAGAR ST NO 2,, NAVA THORALA
NAVA THORALA
RAJKOT
GUJARAT 360001
Mobile No: 79******01

Sub: Risk Assumption Letter

Dear RAGHUBHAI PANCHABHAI RATADIYA,

We value your relationship with ICICI Lombard General Insurance Company Limited and thank you for choosing us as your preferred insurance provider.

Please find enclosed Policy No. 3003/364046446/00/000, The same has been issued based on below mentioned details, provided by you at the time of policy
purchase.

Insured & Vehicle Details

Name of the Insured RAGHUBHAI PANCHABHAI RATADIYA
Period of Insurance Oct 15, 2024 to Oct 14, 2025
Vehicle Make / Model EICHER MOTOR / PRO 1110 H
RTO City GUJARAT-RAJKOT
Vehicle Registration No. GJ03BT4272
Vehicle Registration Date Jul 31, 2015
Engine No. E413CDFE031188
Chassis No. MC2F7HRC0FE104261
Current Year NCB(%) 45%
Vehicle Usage MARKET LOADS
Previous Policy Details
Previous Policy No. 2315204338518202000
Previous Policy Period 15-10-2023 to 14-10-2024
Previous Year NCB(%) 35%
Claims Made Under Previous Policy 0
Previous Insurer Name HDFC
Previous Policy Type Comprehensive Package
1
The commencement of coverage of risk under the policy is subject to realisation of payment of premium in full. In case the premium is not realised due to 0
cheque dishonour or any other reason, the insurance cover shall be void ab-initio.
1
We have issued the policy basis your confirmation that you hold a valid PUC and/or Fitness certificate, as applicable.

Government of India has mandated electronic toll payments using FASTag to reduce vehicular traffic at toll plazas. Customers are advised to comply with the
direction of the government and get their FASTag from Point of Sale locations at Toll Plazas or from Issuer Agency. Please visit http://www.fastag.org/ for
details.

Please check the policy details for accuracy. Should you find any discrepancy / require any changes in the Certificate of Insurance cum Policy Schedule, please
contact us immediately at our toll free number 1800 2666 or email us at customersupport@icicilombard.com, so that we can rectify the same. Absence of any
communication within a period of 15 days of the date mentioned on this letter, would mean that the issued policy is in order and as per your proposal.

Important Points:
a. Any accidental loss, damage and/or liability caused, sustained or incurred, while vehicle not being registered permanently will not be covered.
b. Any minor scratches to the vehcile, paint fading, wear and tear arising out of normal use and requiring touch-up or minor repair under routine maintenance
will not be covered.
c. Any liability of whatsoever nature caused by, contributed by or arising due to the vehicle being driven by a person without having valid driving license will not
be covered.
d. In case of total loss / constructive total loss / Total theft of the vehicle, the claim will be settled at invoice price i.e amount paid by the insured / policyholder at
the time of purchasing the vehicle, excluding subsidy amount, if included in the invoice, or the Insured declared value (IDV) whichever is lower, subject to terms
and conditions of the policy and admissibility of claims.
( Please visist www.icicilombard.com for the policy wordings, for complete details on terms and conditions governing the coverage and NCB)

The information provided is merely illustrative and shall not be construed to be an evidence of existence of a contract of insurance. The Risk Assumption Letter
is to be read in conjunction with the policy and shall be considered null and void without the same.
CORP/SUP/OPI/2014/1777

Oct 14, 2024

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
1
Goods Carrying Vehicles Package Policy 1
Product Code: 3003 UIN: IRDAN115RP0013V01200203

Name of the Insured : RAGHUBHAI PANCHABHAI RATADIYA Policy No. : 3003/364046446/00/000

Address : AT RAMNAGAR ST NO 2,, NAVA THORALA, NAVA THORALA, Period of Insurance : Oct 15, 2024 00:00 to
RAJKOT, GUJARAT 360001 Midnight of Oct 14, 2025
Telephone No : - Mobile No: 79******01 E-Policy No. :
Email Address : ME**********@GMAIL.COM Policy Issued On : Oct 14, 2024
Nominee Name : - Named Passenger's Nominee: Covernote No. : 364046446
Relationship : - RTO Location : GUJARAT-RAJKOT
Age : Hypothecated To : CHOLAMANDALAM INVESTMENT AND
FINANCE CO LTD,RAJKOT
GSTIN No. (Customer) : Vehicle Class : Public Carrier
Servicing Branch Name : Ahmedabad Category :
Invoice No. : 1010241442900
Servicing Branch Address : Third Zodiac Square S G road Ahmedabad Gujarat 380054

Politically Exposed Person (PEP)/close relative of PEP: No

Vehicle Registration No. Make Vehicle Model Model Type of GVW Mfg Yr Carrying Chassis No. Engine No. Trailer
SubClass Build Body Capacity Chassis No.
EICHER PRO FULLY MC2F7HRC0FE1 E413CDFE031
GJ03BT4272 TRUCKS Open 11950 2015 3 0
MOTOR 1110 H BUILT 04261 188
Trailer Body IDV Chassis IDV Trailer Electrical / Electronic Non Electrical Accessories CNG / LPG Unit Total IDV
Registration No. (`) (`) (`) Accessories (`) (`) (`)
(`)
0.00 7,50,000.00 0.00 0.00 0.00 0.00 7,50,000.00
Premium Details
OWN DAMAGE(A) (`) LIABILITY(B) (`)
Basic OD Premium 2,039.00 Basic Third Party Liability 27,186.00
IMT-23 Loading 306.00 Total 27,186.00
Sub Total 2,345.00 Add:
Less: PA Cover for Owner Driver 599.00
No Claim Bonus 45% 1,055.00 Legal Liability to Paid Driver 50.00
Sub-Total Deductions 1,055.00 Legal Liability for Cleaner/Conductor 100.00
Sub-Total 749.00
Total Own Damage Premium(A) 1,290.00 Total Liability Premium(B) 27,935.00
Total Package Premium (A+B) 29,225.00 271
Premium Taxable @ 12% (Basic TP Liability) 27,186.00
- CGST @ 6% 1,631.16
- SGST @ 6% 1,631.16
Premium Taxable @ 18% (Other than Basic TP Liability) 2,039.00
CGST @ 9% 183.51
- SGST @ 9% 183.51

Total Tax Payable in ` 3,629.00

Total Premium Payable in ` 32,854.00

Geographical Area: India Applicable IMT Clauses: 23 , 7

Compulsory Deductible: ` 1,000.00 Voluntary Deductible: ` 0.00

Premium Collection No. 1218404461 Premium Amount (`) 32,854.00 Receipt Date 14-10-2024
GSTIN Reg.No 24AAACI7904G1ZT HSN/SAC code 997134 / GENERAL INSURANCE SERVICES
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.

Limits of Liability: (a) Under Section II-I(i) of the policy: Death of or bodily injury & (b) Under Section II-I(ii) of the policy: Damage to Third Party Property- Such amount as is
necessary to meet the requirements of the Motor Vehicles (Amendment) Act, 2019 ; PA Cover for Owner-Driver under Section III: CSI 15,00,000.00/-. Limitations as to Use:
The Policy covers use only under a permit within the meaning of the Motor Vehicles Act,1988 or such a carriage falling under sub section(3) of Section 66 of the Motor
Vehicles Act,1988. The policy does not cover 1) Use for organised racing, pace making, reliability trails or speed testing, 2) Use whilst drawing a trailer except the towing
(other than for reward) of any one disabled mechanically propelled vehicle 3) Use of carrying passengers in the vehicles; except employees(other than the driver) not
exceeding the number permitted in the registration document and coming under the purview of Workmens's Compensation Act, 1923. Driver's 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
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. 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".
In consideration of the premium for this extension being calculated at a pro-rata proportion of the annual premium, it is hereby declared and agreed by the insured that upon
expiry of this extension, this policy shall be renewed for a period of twelve months, failing which the difference between the extension premium now paid on pro rata basis
and the premium at short period rate shall become payable by the insured.
For Legal interpretation, English version will hold good. Disclaimer: Please visit www.icicilombard.com for the policy wordings, for complete details on terms and
conditions governing the coverage and NCB. This document is to be read with the policy wordings. The policy is valid subject to realization of cheque. We accept premium
only via legally recognized modes. In case of dishonour of premium cheque, the company shall not be liable under the policy and the policy shall be void ab-initio. In case
of any discrepancy with respect to the policy, please revert within 15 days from the policy start date. This policy is underwritten on the basis of the information provided by
CORP/SUP/OPI/2014/1777

Oct 14, 2024

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
1
Goods Carrying Vehicles Package Policy 1
Product Code: 3003 UIN: IRDAN115RP0013V01200203
of any discrepancy with respect to the policy, please revert within 15 days from the policy start date. This policy is underwritten on the basis of the information provided by
you and as detailed in the Risk Assumption Letter shared with you along with the policy. On renewal, the benefits provided under the policy and/or terms and conditions of
the policy including premium rate may be subject to change. Grievance Redressal: For resolution of any query or grievance you may contact us on our toll free no. 1800
2666, or visit any of our branch offices. You can also write to us at customersupport@icicilombard.com. For detailed grievance redressal mechanism please visit the
"Grievance Redressal" section on our website www.icicilombard.com.
The Company reserves the right to cancel this Policy immediately upon becoming aware of any mis-representation, fraud, non-disclosure of material facts or
non-cooperation by or on behalf of the Insured; the Company is not obliged to refund the premium paid under this Policy
In case of total loss / constructive total loss / Total theft of the vehicle, the claim will be settled at invoice price i.e amount paid by the insured / policyholder at the time of
purchasing the vehicle, excluding subsidy amount, if included in the invoice, or the Insured declared value (IDV) whichever is lower, subject to terms and conditions of the
policy and admissibility of claims.
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. In witness whereof, this Policy has been signed at Mumbai on Oct 14, 2024 in lieu of Covernote No. 364046446. The stamp duty of ` 0.50
paid vide deface no. CSD0220242018 dated Apr 10, 2024.
Policy Issuing Office: ICICI Lombard General Insurance Company Limited, ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi,
Mumbai 400 025.
Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or valid fitness certificate, as applicable, on the
date of commencement of the Policy and undertakes to renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during the subsistence of
the Policy. Further, the Company reserves the right to take appropriate action in case of any discrepancy in the PUC or fitness certificate.

Point of Sale (POS) Details

POS Number POS Name Contact Details PAN Card Number
200995907516 RITA RUPESH DAXINI 9712921911 AAZPD3892Q

D:/CLICK/images/Gaurav_Arora.png

Click here or scan the QR code to view the Customer Information Sheet (CIS). It provides an overview
of the policy features, service and claim processes, as well as other important terms.

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2024.10.14 17:51:05 IST
CORP/SUP/OPI/2014/1777

Oct 14, 2024