ORIGINAL FOR RECIPIENT/DUPLICATE FOR SUPPLIER.

TAX INVOICE/CERTIFICATE CUM POLICY SCHEDULE

(FORM 51 OF THE CENTRALMOTOR VEHICLES RULES, 1989)
Policy Type Package Policy( Commercial Vehicle - Passenger Carrying ) Proposal No. & Date R52977056 / 31-Jan-2018
Policy No. & Type 2314/58115107/00/000 Period of Insurance 00:00:00 AM 01-Feb-2018 to midnight on 31-Jan-2019
Policy Issued On 31-Jan-2018 (00:00) Vehicle Identification No. MA3EWDE1S00B83239
Insured Name M/S Grace Tours And Travels Geographical Area INDIA
Invoice No 04MI170016605 Accounting Code of Service 997134
Insured Address 101 H WING RITU PARADISE CHS, PHASE-1, MIRABHAYANDER ROAD, BIHIND VIJAY SALES HATKESH, MIRABHAYANDER,
THANE-401107, 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 392213
Model & Variant WAGON-R MINOR GREEN LXI/MARUTI WAGON R GREEN LXI Non Electrical Accessories 0
Registration No MH04HN4960 Electrical Accessories 0
Year of Manufacture 2017 CNG/ LPG Kit 0
Engine- Chassis No 7877655 - B83239 Total IDV 392213
Cubic Capacity 998
Seating Capacity 5
Type Of Body Saloon
RTO Location MH04HN4960 / THANE
Schedule Of Premium (Amount in Rs.)
OWN DAMAGE SECTION (A) LIABILITY SECTION (B)
Vehicle 5632 Basic Third Party Liability 11316
Elec. Accessories 0 Third Party Liability for Bi-fuel Kit 60
Non- Elec. Accessories 0 Compulsory PACover Premium 0
Kit (IMT-25) 0 PACover for Paid Driver of Rs (200000) each (IMT- 17 ) 120
Extra Premium towards Inbuilt CNG/LPG 282 Legal Liability (WC) to Driver (IMT-28) 50
Basic Premium 5632 Legal Liability to Employees (IMT-37) 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) 11546
Sub-Total Additions 0 Total Premium (A+B) 18574
Deductibles CGST @9% 1672
Voluntary Deductibles (IMT 22A) 0 SGST @9% 1672
Anti-Theft Device (IMT-10) 141 Gross Premium Paid 21918
AAI Membership (IMT-8) 0 Note :
No Claim Bonus 0 0
Discount for vehicles designed for handicapped NA 1. Policy Issuance is the subject to the realisation of cheque.
2. Consolidate stump duty paid to State Exchequer
Sub - Total Deductibles 141 3. The Policy is subject to a compulsory Deductible of Rs 500 (IMT -22)
Add - On Coverages 4. Voluntary excess Rs (0)
Depreciation Waiver 1255 5. Subject to Endorsements IMT 10, 28, 17,
Hydrostatic Lock Cover 0
Return to Invoice 0
Net own Damage Premium (A) 7028
Nominee Details : Nominee Name Age 0 Relation
Payment Method Cheque No./Transaction No. Bank Name Amount
Payment Detail
Auto Debit 22687653 HSBC BANK LTD 21918
Financier Type Not Financed Financier Name NA Financier Branch NA
Persons or Classes of Persons entitled to drive : Any person including 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 when not used for the transport of passengers at the time of the accident and that such a person satisfies the
requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
LIMITATIONS AS TO USE: The Policy covers use only under a permit within the meaning of the Motor Vehicle Act, 1988 or such a carriage falling under Sub-section 3 of Section 66 of the Motor Vehicle's Act 1988.The
Policy does not cover use for: (1) Organised racing, (2) Pace Making (3) Reliability Trials, (4) Speed Testing (5) Use whilst drawing a trailer except the towing (other than for reward) of any one disabled mechanically
propelled vehicle.
LIMITS OF LIABILITY: Under Section II -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 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. Personal Accident cover for Owner - Driver under section IV: Capital Sum Insured (CSI) - Rs. 0
Deductible under Section-I: 500 (Compulsory Deductible Rs. 500 and Imposed 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: The preceding year/20%,
Preceding Two consecutive years/25%, Preceding Three consecutive years/35%, Preceding Four consecutive years/45%, Preceding Five consecutive years/50% of NCB on OD Premium. 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 the certificate relates as well as this certificate of insurance are issued in accordance with the provision of Chapter X and Chapter XI of M.V. Act, 1988.
For UNIVERSAL SOMPO GENERAL INSURANCE COMPANY LIMITED

Authorized Signatory

Policy Issuing Office:-Plot no. EL - 94, KLS tower, TTC industrial area, Nelco, Nr. Suyog Hotel, Mahape, Navi mumbai - 400710
GSTIN: 27AAACU8917F1Z6, CIN No.:U66010MH2007PLC166770
State Name : Maharashtra