Policy Schedule - Motor - Private Car - Package

Policy Number: 606009311610001102 Business Source: 606009

Issuing Office Sales Channel Code: 9000174310
Office Code: 606009 Name: Ms Nikhil Balekundargi
Office Address: BENGALURU - MALLESWARAM
BUSINE Ramchandra Bldg, 73, Sampige,Road,
Opp: Sunil Jewellers,,Malleswaram, Bengaluru - Contact Number: 9886688586
560003.
Contact Number: 23469688

Customer Name: SHRI SOMESHWAR SAHAKARI SAKKARE KARKHANE

Customer ID: 9701021038 PAN:
NIYAMIT
Address: BAILHONGAL, SIDDA SAMUDRA PO, Phone:
MALLAMANA BELAWADI, BELAGAVI, City: BELGAUM - DISTRICT
E-Mail:
OTHERS, District: BELGAUM, State: KARNATAKA, PIN: 591104.

Policy Effective from 12:10 hours, on 13/01/2017 to midnight of 12/01/2018

Premium ` 9,302.00 Cover Note Number and Date NA

Service Tax ` 1,302.00

Swachh Bharat cess ` 47.00 Proposal Number and Date 8800170113001561 Dt. 13/01/2017

Krishi Kalyan cess ` 47.00

Recoverable Stamp Duty ` 0.00 Receipt Number and Date 603900811610006712 Dt. 11/01/2017

Total Amount ` 10,697.00 Previous Policy Number and Expiry Date NA

(Rupees Ten Thousand Six Hundred Ninety Seven Only.)

Vehicle Details
Vehicle IDV ` 1,35,000.00 Regn. Number KA-24-M-1088
IDV (Trailer / Sidecar) NA Engine or M/c No. GA54M69773
Electrical Accessories NA Chassis Number MA1MB2GAK53M98018
Non Electrical Accessories NA Regn. Authority Bailahongal
Fiber Glass Tank NA Geographical Area India
CNG/LPG Unit NA Make Mahindra and Mahindra Limited
Total IDV ` 1,35,000.00 Model Mahindra Classic 550
Addl. Towing Charges NA Variant 2.5 MDI 4WD 8 Seater
CC / GVW 2523 Class of Vehicle Private Car
Licensed Seating / Carrying Capacity 8 Body Type / Color Saloon/Silver
Year of Mfg. 2005 Regn. Date 01/01/2005

Schedule of Premium
Own Damage (`) Legal Liability (`)
Own Damage Cover(Incl. of applicable add-ons) 3,038.00 Legal Liability Cover 6,164.00
Total 3,038.00 Personal Accident 100.00
Total 6,264.00
Vehicle Own Damage Insurance Details
No Claim Bonus% 0 Nil Depreciation Covered No
Compulsory Excess ` 2,000.00
Third Party Insurance Details
Limit of liability under section II-I(i) Such amount as is necessary to meet the requirement of the motor vehicles Act 1988
under section II-I(ii) ` 7,50,000.00 (In respect of any one claim or series of claims arising out of one event/occurrence.)
Personal Accident Cover Details CSI per head
Driver/Cleaner/Conductor 1 person ` 2,00,000.00
Clauses, Endorsements and Warranties Applicable: IMT 17,22.
Limitations 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, f)Reliability Trials, g)Use in connection with Motor Trade.
Persons or Class of Persons entitled to drive: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 the 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"

Printed on 13/01/2017 by ID : 72023, AID : Page no: 1

Motor - Private Car - Package
Policy Number: 606009311610001102 Business Source: 606009
Issuing Office Sales Channel Code: 9000174310
Office Code: 606009 Name: Ms Nikhil Balekundargi
Office Address: BENGALURU - MALLESWARAM
BUSINE Ramchandra Bldg, 73, Sampige,Road,
Opp: Sunil Jewellers,,Malleswaram, Bengaluru - Contact Number: 9886688586
560003.
Contact Number: 23469688

IN WITNESS WHEREOF, the undersigned being duly authorized hereunto set his/ her hand at the office address mentioned above, this 13 January 2017.This
schedule, the attached policy, the clauses, the endorsements and policy wordings as available in the website www.nationalinsuranceindia.com shall be read
together as one contract and any word or expression to which the specific meaning has been attached in any part of this policy or of the schedule shall bear the
same meaning wherever it may appear. It is warranted that IN CASE OF DISHONOUR OF THE PREMIUM CHEQUE, THIS DOCUMENT STANDS
AUTOMATICALLY CANCELLED 'AB-INITIO'

Stamp For and on behalf of

Duty: National Insurance Company Limited
(` 0.50 )

Authorized Signatory

Printed on 13/01/2017 by ID : 72023, AID : Page no: 2

 Motor - Private Car - Package
Policy Number: 606009311610001102 Business Source: 606009
Issuing Office Sales Channel Code: 9000174310
Office Code: 606009 Name: Ms Nikhil Balekundargi
Office Address: BENGALURU - MALLESWARAM
BUSINE Ramchandra Bldg, 73, Sampige,Road,
Opp: Sunil Jewellers,,Malleswaram, Bengaluru - Contact Number: 9886688586
560003.
Contact Number: 23469688

CERTIFICATE OF INSURANCE
Form 51 of the Central Motor Vehicle Rules, 1989
Certificate No.: 606009311610001102 IXI

Particulars of vehicle insured

Reg. Mark,
No. & Place Engine No.& Make, Model & Year of Seating
Type of Body C.C Premium(`)
of Chassis No Variant Manufacture capacity
Registration
Mahindra and
Mahindra
KA-24-M- GA54M69773 Limited,
1088/ MA1MB2GAK53M Mahindra 2005 Saloon 2523 8 ` 9,302.00
Bailahongal 98018 Classic 550 &
2.5 MDI 4WD 8
Seater.

Name of Registration Authority Bailahongal

SHRI SOMESHWAR SAHAKARI SAKKARE KARKHANE NIYAMIT
,BAILHONGAL, SIDDA SAMUDRA PO,
Name & Address of Insured
MALLAMANA BELAWADI, BELAGAVI,BELGAUM - DISTRICT
OTHERS,BELGAUM,KARNATAKA,591104.
Geographical Area India
Business or Profession
Effective date of commencement of Insurance for the purpose of Act. From 12:10 O' Clock on 13/01/2017.
Date of expiry of the insurance Midnight on : 12/01/2018

PERSONS OR CLASS OF PERSONS ENTITLED TO DRIVE

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.

LIMITATIONS 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, f)Reliability Trials, g)Use in connection with Motor Trade.

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.
Full address of Issuing Office: BENGALURU - MALLESWARAM BUSINE For and on behalf of
Ramchandra Bldg, 73, Sampige,Road, Opp: Sunil Jewellers,,Malleswaram, National Insurance Company Limited
Bengaluru - 560003

Date of issue: 13/01/2017 Duly Constituted Attorney(s)

Printed on 13/01/2017 by ID : 72023, AID : Page no: 3