NATIONAL INSURANCE CO.

LTD
Policy Issuing Office: Mumbai DAB II, First Floor, Sterling Cinema Building, 65, Murzaban Street, Fort, Mumbai, Maharashtra
Pin code: 400001 (State Code: 27), Phone No: 022-22015290
PAN: AAACN9967E, GSTIN: 27AAACN9967E1Z3 , Insurer's IRDA Registration Number: 58
Email: coverfox.tieup@nic.co.in Website: https://nationalinsuranceindia.nic.co.in
CIN: U10200WB1906GOI001713
TWO WHEELER PACKAGE POLICY CERTIFICATE CUM POLICY SCHEDULE
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No 26020531196210020451 Proposal No. & Date CFOX11231031, 10-Sep-2019

Policy Issued On 10-Sep-2019 (10:47:48) Tenure 1 year Period of Insurance 17-Sep-2019(00:00:00) To 16-Sep-2020(Midnight)
Insured Name Mr. Jay Prakash Tyagi Previous Policy No. 015877204700 (Expiry : 16-Sep-2019)
Insured Add C/o surendra Singh sukumari bhavan rd no 4 rambagh society bramhpur Previous Insurer Tata AIG General Insurance Company Limited
jaganpura, Patna, BIHAR(State Code: 10)-800027 Mobile: 8210666734
Email: jptyagi93@gmail.com GSTIN No:

Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity
Hero MotoCorp Limited Hero Honda Passion Pro Std 100 2017 2
Body Type Registration No. RTO Invoice Date Fuel Type Chassis No
BR01DE5405 Patna 29-Aug-2017 Petrol MBLHAR187HHE17933
Engine No Vehicle IDV Elec. Accessories Non-Elec. Accessories Total IDV
HA10ACHHE86012 43000 0 0 43000
Schedule of Premium (Amount in Rs.)
Own Damage Premium (A) ₹ Liability Premium (B) ₹
Basic Premium Basic Third Party Liability 752.0
Vehicle 288.27 Sub Total(Third Party Liability) 752.0
Non-Elec. Accessories 0 PA Cover For Owner Driver of Rs. 15 Lakh 295.0
Elec. Accessories (IMT-24) 0 Sub Total(PA Cover) 295.0
Sub Total (Basic Premium) 288.27 Net Liability Premium (B) 1047.0
Add Ons [Nil Depreciation Plus] 245.1 Total Premium (A+B) 1508.0
Sub Total-Addition 245.1 IGST (18.00%) 271.0
Deductibles
No Claim Bonus (25%) 72.07 Gross Premium Paid 1779.0
Sub Total (Deductibles) Addons: Nil Depreciation Plus
Net Own Damage Premium (A) 461
Note:1.Warning that in case of dishonour of the premium cheque, this document stands automatically cancelled 'ab-initio'
2.Consolidated stamp duty paid to state exchequer
3.The policy is subject to compulsory deductible of Rs.100 (IMT-22)
4.Geographical Area-India
5.The insurance company will display terms & conditions on its website https://nationalinsuranceindia.nic.co.in which can be accessed by you online.
*Subject to IMT Endt. Nos.& Memorandum:22
Nominee Details
Name of Nominee Age Relationship with Insured Name of Appointee Relationship with Nominee
Sriniwash Tyagi 58 Father --N.A- --N.A-
Addon Cover(s): 1. Add-ons- If opted, the benefits and exclusions applicable as per insurance company's rules & regulations.
Limitations as to use: The policy covers use of the vehicle for any purpose other than (1) Hire or Reward (2) Carriage of goods (other than samples or personal luggage)
(3) Organized racing (4) Pace making (5) Speed testing (6) Reliability trials (7) Any purpose in connection with motor trade.
Driver’s Clause: Any person including the insured: Provided that the person driving holds an effective driving license at the time of the accident and is not disqualified
from holding or obtaining such license. Provided also that the person holding an effective learner’s license may also drive the vehicle & that such a person satisfies the
requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.
Limits of Liability Clause: a. Under Section II-1(i) of the policy-Death of or bodily injury to any person so far as it is necessary to meet the requirements of the Motor
Vehicle Act 1988. b. Under Section II-1 (ii) of the policy-Damage to property other than the property belonging to the insured or held in trust or in the custody of control of
the insured up to the limit specified Rs. 100000. c. Under Section (iii) of policy- PA cover for owner driver CSI Rs. 1500000/-, TPPD 2 Sum Insured - Rs 100000/-.
Grievance Clause: For resolution of any query or grievance, Insured may contact the respective branch office of the company or may call at (18002007710) or may write
an email at (coverfox.tieup@nic.co.in). In case the insured is not satisfied with the response of the office, insured may contact the Grievance Officer of the Company. In
the event of unsatisfactory response from the Grievance Office, he/she may, subject to vested jurisdiction, approach the Insurance Ombudsman for the redressal of
grievance. Details of Insurance Ombudsman offices are available at IRDA website:www.irda.gov.in , or on the website of General Insurance Council: www.gicouncil.in or
on the company website https://nationalinsuranceindia.nic.co.in. The policy wording with detailed terms, conditions and exclusions are available on our website
https://nationalinsuranceindia.nic.co.in.
No Claim Bonus will only be allowed, provided the policy is renewed within 90 days of the expiry of the previous policy. No Claim Bonus is subject to no claim on the
previous policy. Benefits under the policy stands forfeited if claim is/was made in previous policy.

Hypothecation Details: NA

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Important Notice: The insured is not indemnified, if the vehicle is used or driven otherwise than in accordance with the schedule. Any payment made by the company by
reasons 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 & RIGHT OF RECOVERY”. For legal interpretation, English version will hold good.
SAC: 997134, Description of Service: Motor Vehicle Insurance Services, Place of Supply: BIHAR (State Code: 10), Invoice Number: 40341A9P10020451.
Billdesk Transaction No: QSBI7963856018. 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 Motor Vehicle Act, 1988.
For & On Behalf of NATIONAL INSURANCE CO. LTD

Channel Code :
POSP Name: Mr Sanjay Sharma
Signature
Code: CF/POS/146715

Broker's Name & Add.: Coverfox Insurance Broking Pvt. Ltd. : Unit B2-601, Boomerang, Chandivali Farm Road, Near Chandivali Studio, Andheri East, Mumbai -
400072
Broker's Code : IRDA/ DB 556/13 , Broker Contact No.: 1800 209 9970
For Renewal/Claims assistance - please contact Ins.Co at : 1800 209 9970
Insurance is the subject matter of solicitation

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