Sample Receipt For motor Insurance

Asia Insurance Corporation

No: 32 , Barly _____ Tipe Road

Green Path

Colombo – 03

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RECEIPT

RENEWAL

(THIS IS NOT A TAX INVOICE)

Insured Name & Addess                              Receipt No       : KU00008R64

Mrs. H.M.T Menike                                       Copy                 : CUSTOMER COPY

Herath Stores , koswatta                               Date                  : 02/12/2012

Panadaragama                                                Time                   : 10.45 AM

                                                                          Department       : KURUNAGALA

POLICY NO                  : 97KUD666675                        Buss. Class       : MOTOR

ENDORSMENT NO    : KU00008154567                     Policy Type      : HIRING VEHICLE

Init Sum Insured          : Rs. 1,000,000.00                     Effect Date      : 05/12/2012

New Sum Insured        : Rs.    900,000.00

Period of Cover           : 05/04/2012 – 04/04/2013

Risk Refference           : 48-2264

Particulars	Amount (Rs.)
PREMIUM EXCLUDING SRCC / TC	8,717.50
SRCC PREMIUM	1,000.00
POLICY FEE	200.00
Total Excluding Levies	9,717.50
Other Levies	1462.62
Admin Fee	33.31
Total Includin Levies	11,213.43

Received with thanks a sum of srilankan Rupees. Eleven thousend two hundred and thirteen and cents forty three only

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Prepared By             Checked By              Authorised by             Cashier Signature

Subject to realiztion of the cheque