Ref No.: GEN/WEL/SG/0008.

3/4136194000

Date: 24/01/2024

To,
MR. PATEL NIKUNJKUMAR
PATEL FALIYU, NEAR PARBADI, AT - SARASVANI, TALUKA- PADRA, VADODARA - 391445
Vadodara - 391445
District: VADODARA
GUJARAT, India
Contact Details 9662205457

Policy number: 4136194000

CKYC ID: 60031843423544

Subject: Risk assumption for Kotak Car Secure

Dear MR. PATEL NIKUNJKUMAR,

We welcome you to Kotak Mahindra General Insurance Company Limited and thank you for choosing us as your preferred service
provider.

This is with reference to your above mentioned Policy issued under Kotak Car Secure.

Enclosed please find the Policy Schedule outlining the details of your policy. Kindly note that the proposal is underwritten and policy is
issued based on the information submitted to us by you, as well as acceptance of the terms and conditions. Policy schedule must be read
in conjunction with the product brochure and policy wordings. Please visit https://www.kotakgeneral.com/customer-
support/downloads or scan above QR code for detailed policy wording.

We request you to carefully go through the same once again and in case of any disagreement, discrepancy or clarifications, please call us
on our toll free number 1800 266 4545 or write to us at [email protected] within 15 days from the date of this letter. Alternatively, you can
also write to us at 8th Floor, Zone IV, Kotak Infiniti, Bldg.No. 21, Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad(E),
Mumbai – 400 097, India.

Please note that the information provided by you will be verified at the time of claim and the captioned Policy shall be treated as void in
case of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure in any form whatsoever made by you or by
your agent, on your behalf, at any stage.

In case where premium is not received by us due to cheque dishonour or any other reason, the insurance cover shall be void ab-initio.

As a valued customer, we would like to provide regular updates on your policy through email and SMS. We therefore request you to keep
us updated of any change in your contact details.

Assuring you of our best services at all times.

Thanking you,

Yours sincerely,

For Kotak Mahindra General Insurance Company Limited

Authorised Signatory

Kotak Mahindra General Insurance Company Limited

CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
 Kotak Car Secure UIN:IRDAN152RP0006V02201516;
Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
 Kotak Car Secure
Comprehensive Policy
Certificate cum Policy Schedule
Policy / Certificate No: 4136194000
For any assistance please call 1800 266 4545 or visit www.kotakgeneral.com

INSURED DETAILS POLICY DETAILS

Name: MR. PATEL NIKUNJKUMAR Policy Issuing Office: 502-503, 5Th Floor, Rembrandt Bulding Opp Associated
Petrol Pump,C.G.Road Ellis Bridge,Ahmedabad Ahmedabad Gujarat 380006.
Address: PATEL FALIYU, NEAR PARBADI, AT -
SARASVANI, TALUKA- PADRA, VADODARA - Period of Insurance:
391445 Vadodara - 391445 District: VADODARA
From: 24/01/2024 17:51 to: 23/01/2025 Midnight
GUJARAT(24), India
Type Of Vehicle: Private Car
Phone: NA
Policy issued on: 24/01/2024
Mobile: 9662205457
Cover Note No: NA
Email: [email protected]
Hypothecated to: ICICI BANK LTD
GSTIN:

INTERMEDIARY DETAILS

Intermediary Code 2 5 9 5 1 4 0 0 0 0 Intermediary Name PRAMESH WEALTH PRIVATE LIMITED

Intermediary's Mobile No. 9 4 2 7 7 7 7 9 3 4 Intermediary's Landline No.

VEHICLE DETAILS

Registration Manufacturer Model Variant Year of RTO Location Engine Vehicle Chassis/ Cubic Fuel Seating
Number Manufacture Number Trailer Chassis No. Capacity/KW Type Capacity
GJ06LS8733 FORD ECO 1.5 TITANIUM 2018 VADODARA JP64975 MAJAXXMRKA 1497 Petrol 5
SPORT PLUS JP64975

Insured Declared Value Non - Electrical Electrical & Electronic Trailer (in ₹) CNG / LPG Kit Total Value of the
(IDV) of the Vehicle Accessories fitted to the Accessories fitted to the (in ₹) Vehicle
(in ₹) Vehicle (in ₹) Vehicle (in ₹) (in ₹)

5,47,750 0 0 0 0 5,47,750

PREMIUM COMPUTATION TABLE (IN ₹)

Section I Section II
Own Damage Liability
Basic Own Damage 6,983.26 Basic TP Including TPPD Premium 3,416.00
Add: Total Liability Premium (B) 3,416.00
Add on Covers Total Premium # 8,470.85
Section III
Personal Accident
PA Cover for Owner Driver of ₹ 15,00,000 330.00
Unnamed PA Cover for Passenger ₹ 1,00,000/Per Person 250.00
PA Cover for Paid Driver ₹ 1,00,000/Per Person 50.00
Total Own Damage Premium (A) 15,454.11 Total Personal Accident Premium (C) 630.00
Taxable value of Services (A+B+C) 19,500.11
CGST @ 9% 1,755.01
SGST @ 9% 1,755.01
Total Premium (in ₹ ) 23,010.00
Add on Covers Opted For: Consumable Cover, Depreciation Cover, Engine Protect, Road Side Assistance
# : For the covers opted as shown in Add On Cover Details Table
Geographical Area INDIA Additional Excess ₹ 0 Compulsory Deductibles ₹ 1,000

Voluntary Deductible ₹ 0 Voluntary Deductible for Depreciation Cover ₹ 0 Total Deductible ₹ 1,000

Kotak Car Secure UIN:IRDAN152RP0006V02201516;

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
NOMINEE DETAILS

*Nominee Name *Nominee Age *Relationship *Name of Appointee(if nominee is a minor) Relationship to the
Nominee

GAURI PATEL 36 Wife

ADD-ON COVER DETAILS

Sum
Sr.
Add-On Cover Insured( Premium ( ) Remarks
No.
)
Consumable Cover
1 NA 160.49
UIN: IRDAN152RP0006V02201516/A0012V02201516
Depreciation Cover No. Of Claims:2
2 NA 7,485.00
UIN: IRDAN152RP0006V02201516/A0011V03201516 Voluntary Deductible: 0
Engine Protect
3 NA 325.36
UIN: IRDAN152RP0006V02201516/A0013V02201516
Road Side Assistance
4 NA 500.00
UIN: IRDAN152RP0006V02201516/A0015V02201516

Kotak Car Secure UIN:IRDAN152RP0006V02201516;

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
CUSTOMER DECLARATION FOR CNG/ LPG KIT

I/ We agree and undertake to immediately inform the Company in case of change on account of addition of CNG/LPG kit and obtain necessary endorsement in the
Policy.

DISCLAIMER

For complete details on terms and conditions governing the coverage and NCB please read the Policy Wordings. This document is to be read with the Policy
Wordings(which are also available on the Company website i.e. www.kotakgeneral.com). Please refer to the claim form for necessary documents to be submitted for
processing the claim.

PUC DECLARATION

This policy has been issued subject to valid Pollution Under Control (PUC) Certificate/Fitness Certificate disclosed to our representative / declared by You prior to
commencement of risk under this policy and further undertaking to renew and maintain a valid PUC throughout the duration of the Policy.

LIMITS OF LIABILITY

Under Section II - 1(i) of the policy -> Death of or bodily injury: Such amounts is necessary to meet their requirements of Motor Vehicles Act, 1988.
Under Section II ­ 1(ii) of the policy ­> Damage to Third Party Property ₹ 7,50,000; PA Cover under Section III: for Owner Driver CSI ₹ 15,00,000

LIMITATIONS AS TO USE

Limitation as to use (Package Policy): 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 trails (g)Use in connection with Motor Trade. Note: In case of vehicles used for
Driving Tuition the words “other than for the purpose of driving tuition” to be read after the words „hire or reward.

DRIVER'S CLAUSES

Any person including the insured: Provided that a person driving hold an effective Driving License at the time of accident and is not disqualified from holding or obtaining
such a license. Provided also that the person holding an effective Learners’ License may also drive the Vehicle and that such a person satisfies the requirements of Rule
3 of the Central Motor vehicles Rules 1989.

SPECIAL CONDITIONS

1. Depreciation covers only the depreciation on the replaced parts.

2. Previous policy document is required at the time of claim verification.
3. All type of pre – existing damages or cost of repair of such damage will be excluded at the time of claim settlement.

NO CLAIM BONUS SCALE

Number of Claims % of Discount on Own Damage Premium

No claim made or pending during the preceding full year of insurance 20%

No claim made or pending during the preceding 2 consecutive years of insurance 25%

No claim made or pending during the preceding 3 consecutive years of insurance 35%

No claim made or pending during the preceding 4 consecutive years of insurance 45%

No claim made or pending during the preceding 5 consecutive years of insurance 50%

*No Claim Bonus (NCB) is subject to no claim on the previous policy. Benefits under the policy will be forfeited if claim is/was made in previous policy. Please contact
our Customer Care team in case of wrong NCB % mentioned.

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 Policy 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.
Subject to I.M.T. Endt.Nos. & Memorandum 22, 17, 16, GR36A, 7 Printed/herein/attached hereto Under Hire Purchase Agreement with NA

Kotak Car Secure UIN:IRDAN152RP0006V02201516;

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
TAX DETAILS

Service Tax/GST Registration No. 2 4 A A F C K 7 0 1 6 C 1 Z Z Category : General Insurance Services

SAC Code 997134 Description Motor vehicle insurance services

Invoice Number 4136194000

DECLARATION

I/We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are issued in accordance with the provision of chapter X, XI of
M.V.Act 1988.

In Witness whereof this Policy has been signed for and behalf of 502-503, 5Th Floor, Rembrandt Bulding Opp Associated Petrol Pump,C.G.Road Ellis
Bridge,Ahmedabad Ahmedabad Gujarat 380006. at Mumbai this 24 day of January of 2024

Stamp Duty of 0.50 is paid as provided under Article 47(B) of Indian Stamp Act, 1899 and included in Consolidated Stamp Duty Paid to the Government of Maharashtra
Treasury vide Order of Addl. Controller Of Stamps, Mumbai at General Stamp Office, Fort, Mumbai - 400001., vide this Order No. (LOA/ENF-2/CSD/17/2023/Validity
Period Dt. 12/12/2023 To Dt. 31/12/2025 (O/w.No. 5072)/Date: 12/12/2023).

For Kotak Mahindra General Insurance Company Limited

Authorised Signatory

This document is digitally signed, hence counter signature / stamp is not required.

Kotak Car Secure UIN:IRDAN152RP0006V02201516;

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
 Transcript of Online Proposal - Kotak Car Secure

Important Information for the Insured:

1. This is a transcript of the details declared by you on the e-proposal and shall be the basis of underwriting of the policy. Request you to carefully review the complete
information provided under this transcript and get back to us within 15 days of issuance of this document, in case there is any discrepancy found.
2. The policy is subject to receipt of complete premium and the risk under the Policy shall commence only from the date as specified in the policy schedule.
3. This document has to be read in conjunction with the policy schedule/document.
Refund, if any, with regard to the premium paid, would be processed in the same source / account (net banking / credit card / debit card) from where the premium
4.
payment has been originally made subject to policy terms and conditions.
5. The policy is subject to the underwriting guidelines of the Company and the details as declared by the Insured under the e-proposal.
6. Online premium payment should be made by the policyholder himself. No third party payment should be made using this mode of payment.
7. The Policyholder/ Insured has fully understood the terms and conditions of the Policy including all the features available thereunder.

Proposal No : 202401240096800

Proposal for : Rollover Policy

23,010.00 Premium Amount (Inclusive of taxes)

Type of cover: Comprehensive Policy

Vehicle Make/Model/
Registration No. Type of body Cubic Capacity/KW Fuel Type
Variant

FORD/ECO SPORT/1.5
GJ06LS8733 1497 Petrol
TITANIUM PLUS

Year of Manufacture Insured Declared Value (IDV) Engine Number Chassis Number

2018 5,47,750 JP64975 MAJAXXMRKA JP64975

Special conditions :

PROPOSER / OWNER’S DETAILS

1. Title and Name of the Insured: MR. PATEL NIKUNJKUMAR

2/116,PATEL FALIYU,SARASAVANI,PADRA, VADODARA,SARASAVANI SARASAVANI District: VADODARA 391445

2. Insured Permanent Address*
GUJARAT(24), India

If Correspondence Address different from PATEL FALIYU, NEAR PARBADI, AT - SARASVANI, TALUKA- PADRA, VADODARA - 391445 Vadodara - 391445 District:
Permanent Address,please provide*: VADODARA GUJARAT, India

3.Phone 4.Mobile * 9662205457 5.Email ID* [email protected]

6.Gender 7.Date Of Birth * 8.Nationality Indian Resident

Proposal Date & Time: 24/01/2024 17:51

Policy Start Date: 24/01/2024 17:51

Policy End Date:

23/01/2025 at midnight
(Comprehensive)

Kotak Car Secure UIN:IRDAN152RP0006V02201516;

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
Limitation as to use (Private Car): 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 trails (g)Use in connection with Motor Trade. Note: In case of vehicles used for
Driving Tuition the words “other than for the purpose of driving tuition” to be read after the words „hire or reward.

Driver’s Clauses: Any person including insured: Provided that a person driving hold an effective Driving Licence at the time of accident and is not disqualified from holding
or obtaining such a licence. Provided also that the person holding an effective Learners’ Licence may also drive the Vehicle and that such a person satisfies the
requirement of Rule 3 of the Central Motor Vehicle Rules, 1989.

STATUTORY WARNING PROHIBITION OF REBATES (Under Section 41 of Insurance Act 1938)

1) No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind
of risk relating to lives or property, in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the Policy, nor shall any
person taking out or renewing or continuing a Policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or
tables of the Insurer.
2) Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to ₹ 1,000,000/­
VEHICLE DETAILS

Date of CNG/LPG/Bi Lease / Hire / Hypothecation (Name and Color of Seating

Registration Authority and RTO Location
Registration Fuel address of concerned parties) Vehicle Capacity
ICICI BANK LTD
VADODARA 11/12/2018 Petrol 5
VADODARA, GUJARAT

*Non - Electrical *Electrical & Electronic

*Insured Declared
Accessories Accessories Trailer *CNG / LPG Kit *Total Value
Value
fitted to the Vehicle (in fitted to the Vehicle (in (in INR) (in INR) (in INR)
of the Vehicle (in INR)
INR) INR)

5,47,750 0 0 0 0 5,47,750

PUC - NO

OPTIONAL ADD-ON COVERS

1. Depreciation Cover# 2. Engine Protect #If Depreciation cover is selected: Voluntary Deductible offered under the
“Depreciation Cover”, which would be applied over and above the Compulsory
3. Return to Invoice 4. Consumable Cover Deductible? No

6. Key Replacement
5. Road Side Assistance
Sum Insured
7. Loss of Personal Belongings
8. Tyre Cover
Sum Insured
9. Daily Car Allowance 10. NCB Protect
11. Meter (Switch On/ Switch Off)
12. Battery Protect Cover
Cover

Kotak Car Secure UIN:IRDAN152RP0006V02201516;

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
 RISK INCLUSION / EXCLUSION

*Name of Appointee (if Relationship to the

1. *Personal Accident Cover of INR *Nominee Name and Age *Relationship
nominee is a minor) Nominee
15,00,000 for the Owner Driver
GAURI PATEL 36 Wife

2. Do you wish to include Personal Accident Name CSI Opted (Rs) *Nominee Name Relationship
cover for the Named passenger? No
Please give details mentioned aside:

3. Do you wish to include Personal Accident cover for the Un-named Passengers / hirer / pillion No. of Persons
C. S. I. (Per Person)
passenger? Yes As Per Seating Capacity
Please give details mentioned aside: 5 100000

# The maximum CSI available per person is ₹ 2,00,000, each in multiples of ₹ 10,000.

4. Do you wish to restrict Third Party Property Damage of ₹ 7.5 Lakh to the statutory TPPD liability limit of ₹ 6,000/­ only? No

5. legal liability against Third Party Risks: A) Owner Driver Yes No Any person other than Paid Driver: No

B) Other Employees Yes No If Yes, no. of Person: 0 C) Unnamed Passengers Yes No If Yes, no. of Person: 5

Compulsory Personal Accident (PA) Cover for owner­driver (PA Cover for Owner –Driver is compulsory for individual vehicle owners)
I hereby declare that the Owner Driver does not require Compulsory Personal Accident Cover as
|__| Owner Driver has a separate existing Personal Accident cover against Death and Permanent Disability (Total and Partial) for Sum Insured of atleast 15
lacs.Tenure___ years |_____________| to |_____________|
|__| The Vehicle to be insured is not owned by an individual
|__| The Owner Driver does not have an effective driving license.
(Note: Where the owner driver owns more than one vehicle, compulsory PA cover can be granted for any one vehicle as opted by him/her). Personal Accident cover
for owner driver is compulsory for Sum Insured of 15 lacs for Two-wheeler, Private Car and Commercial Vehicles. Compulsory PA Cover for Owner Drivers cannot be
granted where the vehicle is owned by a company, a partnership firm or a similar body corporate.

PREVIOUS INSURANCE DETAILS

1. Name and address of the previous insurer TATAAIG-NA

2. Previous Policy TypeComprehensivePolicy 3. Previous Policy Number 62000186880100 4. Existing bonus 0 %

5. Period of Insurance 07/12/2022 To 06/12/2023

Yes No. of
6. Details of claims taken in previous policy: Claims & Claim100- 100
Amount :

Whether you are entitled to No Claim Bonus Yes NO

DETAILS OF DEPRECIATION
Table 1:Schedule of depreciation for arriving at IDV:
The Insured's declared value (IDV) of the vehicle will be deemed to be the 'Sum insured' and it will be fixed at commencement of each policy period for each
insured vehicle
Age of The Vehicle % of Depreciation for fixing IDV Age of The Vehicle % of Depreciation for fixing IDV
Not exceeding 6 Months 5% Exceeding 2 years but not exceeding 3 30%
years
Exceeding 6 months but not exceeding 1 15% Exceeding 3 years but not exceeding 4 40%
year years
Exceeding 1 year but not exceeding 2 years 20% Exceeding 4 years but not exceeding 5 50%
years
Note: IDV of obsolete models of vehicles (i.e. Models which the manufacturers have discontinued to manufacture) and vehicles beyond 5 years of age will be
determined on the basis of an understanding between the insurer and the insured.

PAYMENT DETAILS

Payment Mode : PAYMENT AGGREGATOR

Payment Reference No : 19027161021
Payment Amount: 23,010.00
Payment/Transaction Date: 24/01/2024
Bank Details:

I confirm that the premium is paid out of my legitimate sources of fund and the Company has the right to call for documents to establish sources of funds. The
Company has the right to cancel the policy in case I am/have been found guilty by any competent authority or court of law of violating any law/regulation.

Intermediary Code: 2595140000

This electronic proposal is validated by an OTP sent on the registered mobile number of the customer.

Kotak Car Secure UIN:IRDAN152RP0006V02201516;

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
 Kotak Car Secure UIN:IRDAN152RP0006V02201516;
Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152
 TAX INVOICE

Details of Receiver (Billed To) Details of Supplier (billed by)

Kotak Mahindra General Insurance
GSTIN/UIN Name :
Company Limited
Customer ID 1014317519 GSTIN : 24AAFCK7016C1ZZ
Customer Name MR. PATEL NIKUNJKUMAR Pan Number : AAFCK7016C
Email ID [email protected] CIN: U66000MH2014PLC260291
502-503, 5Th Floor, Rembrandt
BuldingOpp Associated Petrol
Contact No 9662205457 Address: Pump,C.G.RoadEllis
Bridge,AhmedabadAhmedabad Gujarat
380006.
PATEL FALIYU, NEAR PARBADI, AT -
SARASVANI, TALUKA- PADRA,
Address Date of Invoice 24/01/2024
VADODARA - 391445, VADODARA,
391445, GUJARAT, India
IMD Code 2595140000 Invoice No 4136194000
Receipt No 1202401494690 Proposal No 202401240096800
Partner Application No Q4C000000041918169
State Code 24 State Code: 24
Place Of Supply Name GUJARAT - 24 State Name GUJARAT
IRN

HSN / SAC Total Value of Supply Taxable value of Supply CGST CGST Amt SGST SGST Amt
HSN/SAC Description
Code (Rs.) (Rs.) Rate (Rs.) Rate (Rs.)
Motor vehicle insurance 997134 19500.11 19500.11 9% 1,755.01 9% 1,755.01
services
Total 19500.11 19500.11 1755.01 1755.01
Total Invoice Value (In
23,010.00
Figure)
Total Invoice Value (In
Twenty Three Thousand Ten
Words)
Whether Tax Payable on a Reverse Basis or Not No

For : Kotak Mahindra General Insurance Company Limited

Authorized Signatory

"I/We hereby declare that though our aggregate turnover in any preceding 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 in terms of the provisions of the said sub-rule."

Kotak Car Secure UIN:IRDAN152RP0006V02201516;

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.kotakgeneral.com IRDAI Reg. No. 152