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Servicing Office Address
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Moradabad Business Office II,NATIONAL INSURANCE CO LTD.,
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MORADABAD BRANCH OFFICE - 1PARK PLAZA, IIND FLOOROPPOSITE
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CIRCUIT HOUSE, DELHI ROADMoradabad
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GSTIN No: 09AAACN9967E1Z1
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RECEIPT
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Customer Details Collection Details
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Name : Mr SANJEEV KUMAR GUPTA Agent Code : 91042400000001
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Address : H. NO.461 KURI RAWANA NEAR SHIV, Collection Number : 46080181250000001157
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MANDIR CHHAJLET , UTTAR PRADESH , Collection Date : 06/06/2025
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MORADABAD Bank Account : 9174
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Pin Code : 244501
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Received with thanks from Sri/Smt Mr SANJEEV KUMAR GUPTA
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a sum of 9288 (RUPEES NINE THOUSAND TWO HUNDRED EIGHTY EIGHT ONLY) by CD
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towards 1 Year Package Policy 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
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1 46080131256160000833 11 C.D CONTROL A/C 5076 0.00 9288.00 -9288.00
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2 46080131256160000833 11 CASH PREMIUM A/C 5083 7872.00 0.00 7872.00
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3 46080131256160000833 11 CGST_UP_Int_Liab 7397 708.00 0.00 708.00
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4 46080131256160000833 11 SGST_UP_Int_Liab 7398 708.00 0.00 708.00
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TOTAL : 9288.00 9288.00 0.00
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Particulars : CD
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For National Insurance Company Ltd.,
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[Link] quote collection no. and date in all correspondeces
[Link] stamp has been defaced and retained at the office against the issued
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policy.
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[Link] 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
notified under sub-rule (4) of rule 48, we are not required to prepare an invoice
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in terms of the provisions of the said sub-rule.
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NIC/UBPORTAL/91042400000081 06/06/2025 07:23 PM
Visit us at [Link] for information on Products, Services and Grievance Redressal.
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Issuing Office Name & Address
MORADABAD BUSINESS OFFICE II ,NATIONAL INSURANCE CO LTD., MORADABAD
BRANCH OFFICE - 1PARK PLAZA, IIND FLOOROPPOSITE CIRCUIT HOUSE, DELHI
ROADMORADABAD
Tel: Fax: 0591 2310573 (G) , 2322057
GSTIN No: 09AAACN9967E1Z1
RSA Service Provider: TVS Automobile Solutions Private Limited
RSA Service Provider Toll Free Number :- 1800 570 1906
For feedback to RSA:- Email: [Link]@[Link]
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: 46080131256160000833 Private Car 1 Year Package from 00:00 Hrs of 07/06/2025 to Midnight of 06/06/2026 IXI
Policy
Insured Details
Name : Mr SANJEEV KUMAR GUPTA
Address : H. NO.461 KURI RAWANA NEAR SHIV, MANDIR CHHAJLET , UTTAR PRADESH , MORADABAD
Pincode : 244501 Telephone : xxxxxxxx24 Email : xxxxxxxxxxd4@[Link]
PAN No. : xxxxxx948B GSTIN No. : Aadhar No. : xxxx xxxx 8151
Channel : D2C INSURANCE BROKING PVT LTD Mobile : 9894771066 Email : [Link]@[Link]
Aadhar : PAN : xxxxxx771A Code. : 460801 / 91042400000001
Vehicle Details
Make & Model Private Car FORD ECOSPORT TITANIUM + MT SPORTS DIESEL
Reg. No. Engine No. Chassis No. Type of Body CC Mfg. Year Seat Cap. Reg. District
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UP-16-AZ-5922 FC84557 MAJAXXMRKAFC84557 SUV 1498 2015 1+4 GAUTAM BUDDHA
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6/2
NAGAR(UP)
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Geographical Area : INDIA.
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Vehicle IDV Non Elec Access. Elec Access. Bi-fuel kit Trailer Total IDV
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Rs.3,00,000 - - - - Rs.3,00,000
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OD Premium Breakup in Rs. TP Premium Breakup in Rs.
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Basic OD Premium 10,290.00 Basic TP Premium 3,416.00
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(+) Electrical Access. Premium - (+) WC for Driver YES 50.00
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(+) Bi-fuel kit Loading - (+) Wider Legal Liability to employees -
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(+) Geographical Area Extension - (+) Geographical Area Extension -
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(-) Vol. Excess Discount - (+) PA to owner driver YES 275.00
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(-) Auto. Assoc Discount - (+) PA to unnamed PAX -
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(-) Anti-theft Discount - (-) Discount For Limited As per MV Act -
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(-) Other Discount - -5,145.00 (+) Bi-fuel kit Loading -
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(-) NCB Discount 20% -1,029.00 TP Total (Rounded Off) 3,741.00
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(+) Nil Depreciation - OD Total (Rounded Off) 4,131.00
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(+) Nil Depreciation Plus - TOTAL PREMIUM 7,872.00
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(+) NCB Protect - GST 1,416.00
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(+) Engine Protect - NET PAYABLE 9,288.00
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(+) Invoice Protect - Collection Number :46080181250000001157 dated 06-Jun-2025
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(+) Consumables Protect - Subject to IMT Endorsement No. 24,25,28
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(+) RSA Protect YES 15.00
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OD Total (Rounded Off) 4,131.00
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Excess : Compulsory: Rs.1,000 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
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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
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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
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 as amended from time to time.
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Under section 1(ii) Damage to third party property is Upto Rs. 7,50,000 . PA Cover under section 3 for owner-driver is Rs. 15,00,000.
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IMPORTANT NOTICE : The Insured is not indemnified if the vehicle is used or driven otherwise than in accordance with this [Link] 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 as amended from time to time 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 : IRDAN058RP0034V01100001
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Financier : SELF OWNED
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Prev Policy : Cholamandalam MS General Insurance Company Ltd. (Pol No: 3362/60083814/000/00 Expiry Date: 06/06/2025)
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Nominee Name : MRS SANJEEV KUMAR GUPTA Relation : WIFE Age : 40 Years
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NOTE : Warranted that in case of dishonour of the premium cheque, this document stands automatically cancelled 'AB-INITIO'.
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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 as amended from time to time.
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Policy Details Cashless Garages Details
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Authorised Signatory
For & On behalf of
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National Insurance Company Limited
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NIC/UBPORTAL/91042400000081 06/06/2025 07:23 PM
Visit us at [Link] for information on Products, Services and Grievance Redressal.
Customer Care Toll Free Number: 1800 345 0330 Email: [Link]@[Link]
