UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
MOTORCYCLE / SCOOTER - PACKAGE
UIN: IRDAN545RP0222V01200708
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 1716013121P109006644 Certificate Number 1716013121P109006644
Customer Id Issuing Office Address Code 171601
23042279800
Name of the Insured MR PALANISAMY P 178,DR. NANJAPPA ROAD, OPP.CHIDAMBARAM PARK
NO: 1/237, POLLACHI ROAD, SANGAM STREET, KURICHI -
641018
641021 .
COIMBATORE
Address of the Insured TAMIL NADU
641021
Telephone (0422) 2230584
COIMBATORE
TAMIL NADU
Business/Occupation None Telephone :
Insured's Declared Value 8760

Period of Insurance From 00:00 Hrs of 16/12/2021 To Midnight of 15/12/2022

Particulars of Vehicle Insured
Registration No.
Trailer Obsolete Vehicle Cubic Seating including
Engine No. Chassis No. Make/Model Type of Body Year of Mfg
Vehicle (if Capacity/KW driver
any)
TN - 37 - AL - 0G1F52180732 MD626AG1952F90105 Solo with Pillion
No TVS / SCOOTY PEP 2005 74 2
3951
Registration Authority Geographical Area Financier
Coimbatore INDIA
Amount in words: One thousand rupees only
Persons or classes of persons entitled to drive
Any person including Insured provided that a person holds 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: 848.00
The policy covers use of the vehicle for any purpose other than CGST(9%): 76.00
a) Hire or Reward
SGST(9%): 76.00
b) Carriage Goods (other than samples or personal luggage)
c) Organized Racing Stamp Duty: 1.00
d) Pace Making Total(Rounded Off): 1,000.00
e) Speed Testing and Reliability Trials Receipt Number : 10117160121110047414
f) Use in connection with Motor Trade Receipt Date: 13/11/2021
DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: AGN1021926
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor AAKASH K.P , Mobile: 8072600424
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: 6000 /- Direct Business:
Development Officer Code:
Subject to IMT Endorsement No.s, terms and conditions printed herein / attached hereto 16,20,22
I/We hereby certify that the policy to which the certificate relates as well as the certificate of insurance
are issued in accordance with provisions of Chapter X & XI of M.V Act, 1988. For and On behalf of
Date of Issue: 13/11/2021 United India Insurance Co. Ltd.
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.
Duly Constituted Attorney

This document is digitally signed

Signer: N MOHAN SANKAR

Date: Mon, Dec 6, 2021 14:09:34 IST
Location: United India Insurance Company Ltd
1/2 Reason: Signing Policy for UIIC
 MOTOR INSURANCE - MOTORCYCLE / SCOOTER - PACKAGE(UIN: IRDAN545RP0222V01200708) POLICY SCHEDULE
Policy Number :1716013121P109006644 Previous Policy No :1716013120P110214665
Geographical Area :India(A) Insurance Start Date & Time :16/12/2021 00:00 (hours)
Insured Name/ID : MR PALANISAMY P/23042279800 Insurance expiry Date & Time :15/12/2022 midnight
Insured address : Policy Issuing Office Address :
NO: 1/237, POLLACHI ROAD, SANGAM STREET, KURICHI - 641021 . 178,DR. NANJAPPA ROAD, OPP.CHIDAMBARAM PARK ,GST No.:- 33AAACU5552C1ZQ
City: COIMBATORE District: COIMBATORE City: COIMBATORE District: COIMBATORE
State: TAMIL NADU Pincode: 641021 State: TAMIL NADU Pincode: 641018
Telephone: Mobile: 9442764254 Telephone:(0422) 2230584
Business Channel Code: AGN1021926 Business Channel Sub Code:
Dealer Name: Agent Name:AAKASH K.P
Dealer Code: Land Line No: ,Mobile:8072600424
VEHICLE DETAILS
Obsolete Vehicle & Engine Year Of
Registration Number TN - 37 - AL - 3951 No & 0G1F52180732 2005
Number Manufacture
RTA Name Coimbatore Chassis Number MD626AG1952F90105 Cubic Capacity/KW 74
Registration Date 04/07/2005 Vehicle Make & Model TVS & SCOOTY PEP Type Of Body Solo with Pillion
Seating Capacity(Including Geographical
AA Membership Number 2
SideCar) Extension
INSURED DECLARED VALUE ( )
Co-
Vehicle Trailer/Sidecar Electrical/Electronic Accessories Non Electrical Accessories CNG Kit LPG Kit Total Insurance
Details
8760 0 0 0 0 0 8760 100%
OTHER DETAILS
Unique
Financier Policy Subject to IMT Endorsements Applicable Addon-covers/Services
Reference Code
16,20,22
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 warlike 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
1500000 Compulsory 100 Imposed 0 Voluntary 0
(Under Section IV)
SCHEDULE OF PREMIUM ( )
A-OWN DAMAGE PREMIUM B-LIABILITY PREMIUM TOTAL PREMIUM
Premium(A+B) 848.00
Basic premium on Vehicle and Accessories B. Basic TP 482.00
CGST(9%) 76.00
A. Basic OD 142.07 Restricted TPPD Cover - 50.00 SGST(9%) 76.00
Total 142.07 Total 432.00 TOTAL PAYABLE PREMIUM 1,000.00
Stamp Duty 1.00
Add : SAC Code 997134
3121I109006644 &
Less : Compulsory PA for Owner Driver 275.00 Invoice No & Date
06/12/2021
No Claim Bonus 50% 71.04 PA for Unnamed persons 70.00 Receipt Number 10117160121110047414
Receipt Date 13/11/2021
Sub Total (Deductions) 71.04 Receipt Amount 1,000.00
Sub Total (Additions) 345.00 Payment Mode
Paying Party MR PALANISAMY P
Gross OD(A) 71.00

Gross TP(B) 777.00

Gross OD & TP:

848.00
(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 : 13/11/2021

In Witness Whereof this policy has been signed at BO 1 COIMBATORE 171601 on this 13th day of November ,2021

CONSOLIDATED STAMP DUTY For United India Insurance Company Limited

PAID AS PER TAMILNADU
GOVERNMENT GO (RT) NO.
123 DATED 15/03/2021 FOR
THE PERIOD 01/04/2021 TO
31/03/2022.
Duly Constituted Attorneys
IP Address: 43.250.42.158
Issuing Agent: AAKASH K.P Printed By : AAKPPP00 @ 06/12/2021 2:09:30 PM Agent User Name: AAKPPP00
Agent Location: 171601 Underwritten By - AAKPPP00 ( DIRECT AGENT )

2/2