UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
PRIVATE CAR -PACKAGE POLICY
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 0913003119P113652557 Certificate Number 0913003119P113652557
Customer Id 23061219386 Issuing Office Address Code 091300
Name of the Insured MR N TAMILSELVAN DIVISIONAL OFFICE- KARUR, NO 43 & 45, THIRUVIKA ROAD ( THIRUVALLUVAR GROUND
S/O NAVAMANI,3/158 MOCHAKOTTAM PALAYAM, ANDAN KOVIL SOUTH SIDE)
WEST,KARUR
639001
Address of the Insured KARUR
KARUR
639002 TAMIL NADU
TAMIL NADU
Business/Occupation Others Telephone: 43652914 Telephone (4324) 260744,(4324) 260258

Insured's Declared Value 269593

Period of Insurance From 00:00 Hrs of 23/01/2020 To Midnight of 22/01/2021

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)
VOLKSWAGEN /
VENTO(2010 -
TN - 47 - AE - 6699 No CLN181237 WVWM11603CT020399 SEDAN 2011 1598 5
2012) IPL
EDITION

Registration Authority Geographical Area Financier

TN47 KARUR - 639001 INDIA
Amount in words: Eleven thousand three hundred four 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: 11,304.00

The policy covers use of the vehicle for any purpose other than CGST(9%): 1,017.00
a) Hire or Reward
b) Carriage of Goods (other than samples or personal luggage) SGST(9%): 1,017.00
c) Organized Racing Stamp Duty: 1.00
d) Pace Making Total (Rounded Off) : 13,338.00
e) Speed Testing and Reliability Trails
Receipt Number : 10109130019114568188
f) Use in connection with Motor Trade
Receipt Date: 22/01/2020
DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: AGD0095018
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor CHINNAPPAN R , Mobile: 9443652914
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 16,17,22
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

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 :0913003119P113652557 Previous Policy No :0913003118P113646373
Geographical Area :India(A) Insurance Start Date & Time :23/01/2020 00:00 (hours)
Insured Name/ID : MR N TAMILSELVAN/23061219386 Insurance expiry Date & Time :22/01/2021 midnight
Insured address : Policy Issuing Office Address :
S/O NAVAMANI,3/158 MOCHAKOTTAM PALAYAM, ANDAN KOVIL WEST,KARUR DIVISIONAL OFFICE- KARUR, NO 43 & 45, THIRUVIKA ROAD ( THIRUVALLUVAR GROUND SOUTH SIDE)
City: KARUR District: KARUR ,GST No.:- 33AAACU5552C1ZQ
State: TAMIL NADU Pincode: 639002 City: KARUR District: KARUR
Telephone:43652914 Mobile: 9087772244 State: TAMIL NADU Pincode: 639001
Telephone:(4324) 260744,(4324) 260258
Business Channel Code:AGD0095018 Business Channel Sub Code:
Dealer Name: Agent Name:CHINNAPPAN R
Dealer Code: Land Line No.: ,Mobile:9443652914
VEHICLE DETAILS
Registration Number TN - 47 - AE - 6699 Obsolete Vehicle & Engine No & CLN181237 Year Of Manufacture 2011
Number Vehicle Weight(Kg.)
RTA Name TN47 KARUR - 639001 Chassis Number WVWM11603CT020399 Cubic Capacity/KW 1598
VOLKSWAGEN & VENTO(2010 - 2012)
Registration Date 17/02/2012 Vehicle Make & Model Type Of Body SEDAN
IPL EDITION
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
269593 0 0 0 0 0 269593 100%
OTHER DETAILS
Unique
Financier Policy Subject to IMT Endorsements Applicable Addon-covers/Services
Reference Code
16,17,22
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 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
1500000 Compulsory 2000 Imposed 0 Voluntary 0
(Under Section IV)
SCHEDULE OF PREMIUM( )
A-OWN DAMAGE PREMIUM B-LIABILITY PREMIUM TOTAL PREMIUM
Premium(A+B) 11,304.00
Basic premium on Vehicle and Accessories B. Basic - TP 7,890.00
CGST(9%) 1,017.00
A. Basic - OD 2,838.81 Total 7,890.00
SGST(9%) 1,017.00
Total 2,838.81
TOTAL PAYABLE PREMIUM 13,338.00
Add :
Stamp Duty 1.00
Compulsory PA for Owner Driver 275.00
SAC Code 9971
PA to Paid driver 50.00 3119I113652557 &
Invoice No & Date
Gross OD(A) 2,839.00 22/01/2020
PA for Unnamed persons 250.00 Receipt Number 10109130019114568188
Receipt Date 22/01/2020
Receipt Amount 13,338.00
Sub Total (Additions) 575.00
Payment Mode CASH
Paying Party MR N TAMILSELVAN
Gross TP(B) 8,465.00

Gross OD & TP:

11,304.00
(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:22/01/2020

In Witness Whereof this policy has been signed at DO KARUR 091300 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
Issuing Agent: CHINNAPPAN R Printed By : CUSTOMER @ 22/01/2020 2:20:45 PM Agent User Name: CHIRRR001
Agent Location: 091300 Underwritten By - CHIRRR001 ( DIRECT AGENT )

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