Service Branch Address: office no.29&30, 3rd Floor, B wing, Jewel of Pimpri Building, ,Kamala Cross Road, Opp.

Pimpri Chinchwad Municipal Corporation

on Mumbai -Pune Road ,

MR. Vilas B Wagh

AP Intermediary Code: BR150000
NIPANI NIMGAON MALI Intermediary Name: PROBUS BROKERS
CHINCHORE
AHMEDNAGAR Contact: 18008336700
PIMPRICHINCHWAD,
MAHARASHTRA
414602
Telephone :
Mobile : xxxxxx5403

CERTIFICATE OF INSURANCE & POLICY SCHEDULE

(See Form 51 of The Central Motor Vehicles Rules, 1989) Motor Vehicles Act, 1988
Private Car Policy – Liability only
Policy Period:Period of insurance
Certificate of Insurance and Policy No.
VPTP306470000100
From 18:55:38 hours on 26/07/2022 To 23:59:59 hours on 25/07/2023
INSURED DETAILS
Name of Insured Geographical Registration
Business/Profession Registration Date
Area Authority
MR. Vilas B Wagh INDIA PIMPRICHINCHWAD 01/04/2012
VEHICLE DETAILS
INDIGO LX TDI - 5
Registration Number MH-14-DN-4830 Model Description Gross Vehicle Weight(Kgs) 0
SEATER
Engine Number 14CRAIL08GXYW24483 Type of Body SEDAN Seating Capacity (including Driver) 5
Chassis Number MAT601481CWG34113 Cubic Capacity 1405
Make of the Vehicle TATA MOTORS LTD. Year of Manufacture 2012 Total Premium (in Rs.) 4,030.88
DRIVER: Any person including the Insured: • Provided that a person driving holds an
LIMITATIONS AS TO USE:The Policy covers use of the vehicle for any purpose
effective driving license at the time of the accident and is not disqualified from holding or
other than: a) Hire or Reward b) Carriage of goods (other than samples or personal
obtaining such a license. • Provided also that the person holding an effective Learner’s
luggage) c) Organised racing d) Pace making e) Speed testing f) Reliability Trials g) Any
License may also drive the vehicle and that such a person satisfies the requirements of
purpose in connection with Motor Trade.
Rule 3 of The Central Motor Vehicles Rules, 1989.
LIMITS OF LIABILITY:
Under Section I-1 (i) of the Policy - Death of or bodily injury - Such amount as is necessary to meet the requirements of the Motor Vehicles Act, 1988.Under Section I-1 (ii) of the
Policy -Damage to Third Party Property - Rs Rs.7,50,000-In respect of any one claim or series of claims arising out of one event/-
Nominee Name : Nominee Age : Relationship with :
Guardian Name : Guardian Age : Guardian Relation :
LIABILITY
1. Basic premium including premium for TPPD 3,416.00
2. Less: For restricted TPPD cover for Rs.6000/- (IMT 20) 0.00
3. Trailers (IMT30) 0.00
4. Bi-fuel kit (CNG) 0.00
Add:Personal Accident Benefits
5. Under Section III (Owner Driver), CSI Rs. 15,00,000.00 0.00
6. Named Passengers, CSI Rs.0 each as per list attached (IMT 15) 0.00
7. Unnamed Passengers, CSI Rs.0.00 0.00
8. Geographical Area Extn.Endt.IMT-1 0.00
9. P.A Cover to Paid Driver, CSI Rs.0.00 (IMT 17) 0.00
ADD:Legal Liability ADD: SGST 307.44
10.To Paid Driver (IMT 28) 0.00
11.To Employees (IMT 29) 0.00
TOTAL LIABILITY PREMIUM 3,416.00 TOTAL PREMIUM 4,030.88
Subject to IMT Endt. Nos. & memorandum 22 (refer Terms & Conditions for relevant wording) Signature Not
Verified
In Witness whereof this Policy has been signed at Chennai on 26/07/2022 in lieu of Cover note No. IMC1157646 dated . 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 the Motor Vehicles Act, 1988. Digitally signed by
TAIKAD MAHADEVAN
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 SHYAMSUNDER
by reason of wider terms appearing
in the Certificate in order to comply with the Motor Vehicles Act, 1988 is recoverable from the Insured. See the clause headed "AVOIDANCE OF CERTAIN TERMS AND RIGHT Date:OF2022.07.24
RECOVERY" under Policy
Terms and Conditions. 18:55:49 GMT+05:30
For Royal Sundaram General Reason: For
Insurance Co. Limited
RoyalSundaram
Location: Chennai

Authorised Signatory
Consolidated Stamp Duty Paid to Govt of TamilNadu This document is digitally signed, hence counter signature / stamp is not required.

For Legal interpretation, English version will hold good. GSTIN: 27AABCR7106G1ZJ UIN: IRDAN102P0004V02201617 PAN Number: AABCR7106G
90c01a5be4e9dbbb0d504c437e39c8a6

Document Code:
Fastag ID:
Point of Sales Person Name : AVINASH C AMBUDKAR Contact Number : Mobile No.:
Aadhaar Card Number : XXXX-XXXX-7152 PAN Number : AXAPA0765F
 GST Invoice
Royal Sundaram General Insurance Co. Limited
office no.29&30, 3rd Floor, B wing, Jewel of Pimpri Building,
Kamala Cross Road, Opp. Pimpri Chinchwad Municipal Corporation on Mumbai -Pune Road ,
Chinchwad - 411018
GSTIN: 27AABCR7106G1ZJ

Policy Number : VPTP306470000100

GST Invoice Number : VPTP30647000000
Inception Date : 26/07/2022
Policy Posted Date : 24/07/2022 18:55:38

Address of insured (Interstate):

AP
NIPANI NIMGAON MALI CHINCHORE
AHMEDNAGAR
AHMEDNAGAR
State:MAHARASHTRA
Pincode: 414602

Accounting code of service : 997134

Description of service: Motor vehicle insurance services

Taxable premium 3,416.00

SGST 9% 307.44

CGST 9% 307.44

Gross premium 4,030.88

Indication if tax payable under reverse charge - No

Note:“This document is digitally signed”