UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
Policy No.
Customer Id
Name of the Insured
Address of the Insured
Business/Occupation
PRIVATE CAR-PACKAGE
UIN: IRDAN545RP0047V01199900
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
2705013121P108852296 Certificate Number 2705013121P108852296
23095599422 Issuing Office Address Code 270501
MR RAJ KISHORE DEWANGAN R-EMINENCE COMMERCIAL COMPLEX", 1ST FLOOR
S/O RAM GOPAL DEWANGAN, N B/131,SWARNBHOOMI AMASEONI, G.E. ROAD, TATIBANDH, RAIPUR (C.G.)
492099
RAIPUR
CHATTISGARH
RAIPUR
492001
CHATTISGARH Telephone (0771) 2573217
None Mobile No.- 9691698869

Insured's Declared Value 758646

Period of Insurance From 00:00 Hrs of 03/12/2021 To Midnight of 02/12/2022

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)
HYUNDAI /
CG - 04 - LZ - CRETA(2015 -
No G4FGHW596699 MALC381CLHM335806 2018) 1.6 SX SUV 2017 1591 5
6040
PLUS AT PETROL

Registration Authority Geographical Area Financier

CG04 RAIPUR INDIA
Amount in words: Fifteen thousand one hundred ninety-seven 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: 12,879.00
The policy covers use of the vehicle for any purpose other than
CGST(9%): 1,159.00
a) Hire or Reward
b) Carriage of Goods (other than samples or personal luggage) SGST(9%): 1,159.00
c) Organized Racing Stamp Duty: 1.00
d) Pace Making Total (Rounded Off) : 15,197.00
e) Speed Testing and Reliability Trails
Receipt Number : 10127050121109886348
f) Use in connection with Motor Trade
Receipt Date: 01/12/2021
DebitNote Number:
Document Date:
Limits of Liability MISP Name: JAIKA
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor MISP Code: AUTOMOBILES PVT.
Vehicles Act 1988 Intermediary Name: LTD.
Under Section II-I (ii) Damage to third party property in respect of any one claim or series of Intermediary Code: MISP000666
claims arising out of one event 750000 , Mobile: 9981991841 JAIKA INSRUANCE
Designated Person Name : BROKERAGE PVT LTD
BRC0000168
Direct Business:
Development Officer Code: GULAB SAHU

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: 01/12/2021

Amount Subject to Reverse Charges-NIL

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.

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.

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 MOTOR INSURANCE - PRIVATE CAR PACKAGE(UIN: IRDAN545RP0047V01199900) POLICY SCHEDULE
Policy Number :2705013121P108852296 Previous Policy No :2705013120P109896413
Geographical Area :India(A) Insurance Start Date & Time :03/12/2021 00:00 (hours)
Insured Name/ID : MR RAJ KISHORE DEWANGAN/23095599422 Insurance expiry Date & Time :02/12/2022 midnight
Insured address : Policy Issuing Office Address :
S/O RAM GOPAL DEWANGAN, N B/131,SWARNBHOOMI AMASEONI, R-EMINENCE COMMERCIAL COMPLEX", 1ST FLOOR G.E. ROAD, TATIBANDH, RAIPUR (C.G.) ,GST No.:-
City: RAIPUR District: RAIPUR 22AAACU5552C1ZT
State: CHATTISGARH Pincode: 492001 City: RAIPUR District: RAIPUR
Telephone: Mobile: 9691698869 State: CHATTISGARH Pincode: 492099
Telephone:(0771) 2573217
MSIP Name/Code:JAIKA AUTOMOBILES PVT. LTD. / MISP000666 Business Channel Sub Code:

Designated Person Name :GULAB SAHU Land Line No.: ,Mobile:9981991841

VEHICLE DETAILS
Registration Number CG - 04 - LZ - 6040 Obsolete Vehicle & Engine No & G4FGHW596699 Year Of Manufacture 2017
Number Vehicle Weight(Kg.)
RTA Name CG04 RAIPUR Chassis Number MALC381CLHM335806 Cubic Capacity/KW 1591
HYUNDAI & CRETA(2015 - 2018)
Registration Date 30/11/2017 Vehicle Make & Model Type Of Body SUV
1.6 SX PLUS AT PETROL
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
758646 0 0 0 0 0 758646 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
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) 12,879.00
Basic premium on Vehicle and Accessories B. Basic - TP 7,890.00
CGST(9%) 1,159.00
A. Basic - OD 8,115.69 Total 7,890.00
SGST(9%) 1,159.00
Total 8,115.69
TOTAL PAYABLE PREMIUM 15,197.00
Add :
Stamp Duty 1.00
Compulsory PA for Owner Driver 275.00
SAC Code 997134
Less : PA for Unnamed persons 3121I108852296 &
Invoice No & Date
(No of persons: 4, SI per occupant: 200.00 01/12/2021
No Claim Bonus 45% 3,652.06 100000/-) Receipt Number 10127050121109886348
Sub Total (Deductions) 3,652.06 Receipt Date 01/12/2021
LL to Paid Driver IMT 28 50.00
Receipt Amount 15,197.00
Payment Mode
Gross OD(A) 4,464.00 Sub Total (Additions) 525.00 Paying Party MR RAJ KISHORE
DEWANGAN

Gross TP(B) 8,415.00

Gross OD & TP:

12,879.00
(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:01/12/2021

In Witness Whereof this policy has been signed at BO TATIBANDH 270501 on this 01st day of December ,2021

For United India Insurance Company Limited

Affix Policy Stamp

Duly Constituted Attorneys

IP Address: 10.95.40.80
JAIKA AUTOMOBILES PVT.
Issuing MISP: Printed By : CUSTOMER @ 28/11/2022 2:14:09 PM MISP User Name: ASH33305
LTD.
MISP Location: 270501 Underwritten By - ASH33305 ( BO UW CUM CASHIER )

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

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