UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
PRIVATE CAR -PACKAGE POLICY
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 2703813119P113648675 Certificate Number 2703813119P113648675
Customer Id 23059388733 Issuing Office Address Code 270381
Name of the Insured MR DILIP KUMAR CHANDRAKAR MICRO OFFICE,PARAS COMPLEX,OPP- STATE BANK OF INDIA,GURDWARA STATION ROAD
QTR NO. 14 C ST AVE SECTOR 6, BHILAI
491001
Address of the Insured DURG DURG
490006 CHATTISGARH
CHATTISGARH
Business/Occupation Others Telephone: 07884013045 Telephone (0788) 4013045
Insured's Declared Value 265000

Period of Insurance From 00:00 Hrs of 24/01/2020 To Midnight of 23/01/2021

Particulars of Vehicle Insured
Registration No.
Cubic Seating including
Trailer Obsolete Vehicle Engine No. Chassis No. Make/Model Type of Body Year of Mfg
Vehicle Capacity/KW driver
(if any)
MARUTI SUZUKI
CG - 07 - MB - / SWIFT(2014 -
No D13A1140570 MA3FHEB1S00192598 2018) LXI ABS O Saloon 2012 1197 5
2022

Registration Authority Geographical Area Financier

CG07 DURG INDIA
Amount in words: Five thousand six hundred eighty rupees only
Persons or classes of persons entitled to drive
Any person including Insured provided that a person 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 Learner's Licence may also drive the vehicle and such a person satisfies the requirements of Rule 3 of Central Motor Vehicle Rule, 1989.

Limitations as to use Premium: 5,680.00

The policy covers use of the vehicle for any purpose other than
CGST(9%): 511.00
a) Hire or Reward
b) Carriage of Goods (other than samples or personal luggage) SGST(9%): 511.00
c) Organized Racing Stamp Duty: 1.00
d) Pace Making Total (Rounded Off) : 6,702.00
e) Speed Testing and Reliability Trails
f) Use in connection with Motor Trade Receipt Number : 10127038119114564102
Receipt Date: 22/01/2020
DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: AGD0126618
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor DHARMENDRA KUMAR JOSHI , Mobile: 9685264693
Vehicles Act 1988 Dealer Name/Code:
Under Section II-I (ii) Damage to third party property in respect of any one claim or series of
claims arising out of one event 750000 Direct Business:
Development Officer Code:
Subject to IMT Endorsement No.s, terms and conditions printed herein / attached hereto 16,22,28
I/We hereby certify that the policy to which the certificate relates as well as the certificate of insurance For and On behalf of
are issued in accordance with provisions of Chapter X & XI of M.V Act, 1988. United India Insurance Co. Ltd.

Duly Constituted Attorney:

Date of Issue: 22/01/2020

Note:-With reference to IRDAI circular no IRDAI/NL/CIR/MOTP/170/10/2018 dated 09/10/2018 and as per the declaration given in the proposal form by owner driver Compulsory Personal
Accident (CPA) cover is removed, since he/she is not holding a valid driving license.

Amount Subject to Reverse Charges-NIL

IMPORTANT NOTICE: KINDLY UPDATE YOUR AADHAAR NO. AND PAN/FORM 60. PLEASE IGNORE IF ALREADY UPDATED.
The genuineness of the policy can be verified
through "Verify Your Policy" link at
www.uiic.co.in.
 MOTOR INSURANCE - PRIVATE CAR PACKAGE POLICY SCHEDULE
Policy Number :2703813119P113648675 Previous Policy No :2703813118P113719105
Geographical Area :India(A) Insurance Start Date & Time :24/01/2020 00:00 (hours)
: MR DILIP KUMAR
Insured Name/ID Insurance expiry Date & Time :23/01/2021 midnight
CHANDRAKAR/23059388733
Insured address : Policy Issuing Office Address :
QTR NO. 14 C ST AVE SECTOR 6, BHILAI MICRO OFFICE,PARAS COMPLEX,OPP- STATE BANK OF INDIA,GURDWARA STATION ROAD ,GST No.:-
City: DURG District: DURG 22AAACU5552C1ZT
State: CHATTISGARH Pincode: 490006 City: DURG District: DURG
Telephone:07884013045 Mobile: 9926196111 State: CHATTISGARH Pincode: 491001
Telephone:(0788) 4013045
Business Channel Code:AGD0126618 Business Channel Sub Code:
Dealer Name: Agent Name:DHARMENDRA KUMAR JOSHI
Dealer Code: Land Line No.: ,Mobile:9685264693
VEHICLE DETAILS
Registration Number CG - 07 - MB - 2022 Obsolete Vehicle & Engine No & D13A1140570 Year Of Manufacture 2012
Number Vehicle Weight(Kg.)
RTA Name CG07 DURG Chassis Number MA3FHEB1S00192598 Cubic Capacity/KW 1197
MARUTI SUZUKI & SWIFT(2014 -
Registration Date 14/03/2012 Vehicle Make & Model Type Of Body Saloon
2018) LXI ABS O
AA Membership Number Geographical Extension Seating Capacity(Including 5
Driver)
INSURED DECLARED VALUE ( )
Co-
Vehicle Trailer Electrical/Electronic Accessories Non Electrical Accessories CNG Kit LPG Kit Total Insurance
Details
265000 0 0 0 0 0 265000 100%
OTHER DETAILS
Unique
Financier Policy Subject to IMT Endorsements Applicable Addon-covers/Services
Reference Code
16,22,28
PERSONS OR CLASS OF PERSONS ENTITLED TO DRIVE:As narrated in the certificate of insurance attached herewith.
LIMITATIONS AS TO USE:As narrated in the certificate of insurance attached herewith.
LIMITS OF LIABILITY:As narrated in the certificate of insurance attached herewith.
EXCLUSIONS:(1)Any accidental Loss Or Damage and/or liabilty caused sustained or incurred outside the geographical area.(2)Any claim arising out of any contractual liability.(3)Any accidental loss or damage to any
property whatsoever or any loss or expense whatsoever resulting or arising there from or any consequential loss.(4)Any liability of whatsoever nature directly or indirectly caused by or contributed to or by arising out of ionizing
radiations or contamination by radioactivity from any nuclear fuel.For the purpose of this exception,combustion shall include any self sustaining process of nuclear fission.(5)Any accidental loss or damage or liability directly or
indirectly caused by or contributed to by or arising from nuclear weapons material.(6)Any accidental loss damage and/or liability directly or indirectly or proximately or remotely occasioned by or contributed to by or traceable
to or arising out of or in connection with war, invasion, the act of foreign enemies, hostilities or war like operations (whether before or after declaration of war), civil war, mutiny rebellion, military or usurped power or by any
direct or indirect consequences of any of the said occurrences or any consequences thereof and in default of such proof the Company shall not be liable to make any payment in respect of such a claim.

PA Cover CSI( ) DEDUCTIBLES (Under Section I)( )

Owner Driver CSI
0 Compulsory 1000 Imposed 0 Voluntary 0
(Under Section IV)
SCHEDULE OF PREMIUM( )
A-OWN DAMAGE PREMIUM B-LIABILITY PREMIUM TOTAL PREMIUM
Premium(A+B) 5,680.00
Basic premium on Vehicle and Accessories B. Basic - TP 3,221.00
CGST(9%) 511.00
A. Basic - OD 2,886.05 Total 3,221.00
SGST(9%) 511.00
Total 2,886.05
TOTAL PAYABLE PREMIUM 6,702.00
Add :
Stamp Duty 1.00
PA for Unnamed persons 100.00
SAC Code 9971
Less : LL to Paid Driver IMT 28 50.00 3119I113648675 &
Invoice No & Date
22/01/2020
No Claim Bonus 20% 577.21
Receipt Number 10127038119114564102
Sub Total (Deductions) 577.21 Sub Total (Additions) 150.00 Receipt Date 22/01/2020
Receipt Amount 6,702.00
PAYMENT GATEWAY FOR
Gross OD(A) 2,309.00 Gross TP(B) 3,371.00 Payment Mode
CD
Gross OD & TP: Paying Party MR DILIP KUMAR
5,680.00 CHANDRAKAR
(A) + (B)

TERMS & CONDITIONS:As per the Indian Motor Tariff,personal copy of the same is available free of cost on request.Further the Indian Motor Tariff is also available and displayed at all United India Insurance company Offices
and on Website www.uiic.co.in
DISCLAIMER:The policy stands Cancelled or void in the event of Cheque Dishonored.The company may cancel the policy by sending 7 days notice in case of fraud,misrepresentation,nondisclosure of material fact or non co-
operation of the insured.
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 fom the Insured. See the clause headed "AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY".For Legal interpretation, English Version will hold good.In
case of accident the insured must inform United India Insurance Co. Immediately to arrange spot survey.
Anti Money Laundering Clause:-In the event of a claim under the policy exceeding 1 lakh or a claim for refund of premium exceeding 1 lakh, the insured will comply with the provisions of AML policy of the company. The
AML policy is available in all our operating offices as well as Company's web site.

LET US JOIN THE FIGHT AGAINST CORRUPTION. PLEASE TAKE THE PLEDGE AT https://pledge.cvc.nic.in.

Date & Signature of Proposal:22/01/2020

In Witness Whereof this policy has been signed at MO DURG BHILAI 270381 on this 22nd day of January ,2020

For United India Insurance Company Limited

Affix Policy Stamp

Duly Constituted Attorneys

IP Address: 10.90.240.24
DHARMENDRA KUMAR
Issuing Agent: Printed By : CUSTOMER @ 22/01/2020 12:58:07 PM Agent User Name: DHAJOS00
JOSHI
Agent Location: 270381 Underwritten By - DHAJOS00 ( DIRECT AGENT )

This is a system generated document and any manual alteration / correction / overwriting in the document will make it invalid.