UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
MISCELLANEOUS AND SPECIAL TYPE OF VEHICLES - PACKAGE POLICY
UIN. IRDAN545RP0049V01199900
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 2412003123P108075446 Certificate Number 2412003123P108075446
Customer Id 23051341533 Issuing Office Address Code 241200
Name of the Insured MR KUMAR SWAMI UMAMAHESWARA RAO BLDG,
S/O SAKAPPA R/O KOMBHIHALLI KUDLIGI VIJAYANAGARA FLOOR NO:1, STATION ROAD, HOSPET, BELLARY, KARNATAKA - 583201
583201
Address of the Insured 583135 BELLARY
BELLARY KARNATAKA
KARNATAKA Telephone (08394) 229227,(08394) 228261
Business/Occupation None Mobile No.- 9741764858
Effective date of commencement of Insurance for the Insured's Declared Value 120000
purpose of Act from 00:00 Hrs on 11/10/2023
Date of Expiry of the Insurance Midnight on 10/10/2024

Particulars of Vehicle Insured

Registration No.
Type of Year of HP/Cubic
Trailer Obsolete Vehicle Engine No. Chassis No. Make/Model GVW
Vehicle Body/Vehicle Mfg Capacity
(if any)
Open/Agricultural
MASSY
Vehicles not
KA - 35 - TA - 2118 KA35TA2119 No S3251E48458 804123 FERGUSON / MF 2013 35 1780
rateable under
1035 DI
Agri Tractors

Registration Authority Geographical Area Financier Public / Private

KA35 HOSPET - 583201 INDIA Not Applicable
Amount in words: Fourteen thousand nine hundred twenty-eight 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.
Note:- The policy does not cover liability for death, bodily injury or damage as excluded insection 150 (2) (ii) and (iii); (b) and (c) of the Motor Vehicles Act, 1988.
Limitations as to use Premium: 12,650.00
The policy covers use only under a permit within the meaning of Motor Vehicles Act, 1988 or CGST(9%): 1,139.00
such a carriage falling under Subsection 3 of Section 66 of the Motor Vehicles Act, 1988.
The policy does not cover use for: SGST(9%): 1,139.00
a) Organized Racing Stamp Duty: 1.00
b) Pace Making Total(Rounded Off): 14,928.00
c) Reliability Trials
Receipt Number : 10124120023109249681
d) Speed Testing
Receipt Date: 10/10/2023
DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: AGN1042406
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor MOHAMMED GOUSE , Mobile:
Vehicles Act 1988 9880440256
Under Section II-I (ii) Damage to third party property in respect of any one claim or series of Dealer Name/Code:
claims arising out of one event: 750000 /-
Direct Business: BAS25601
Business Associate Code:
MUDHOL S V
Subject to IMT Endorsement No.s, terms and conditions printed herein / attached hereto 22,28
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.
Date of Issue: 10/10/2023
For and On behalf of
Amount Subject to Reverse Charges-NIL
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18
United India Insurance Co. Ltd.
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.
Duly Constituted Attorney

This document is digitally signed

Signer: KALAIVENI SUBBIAH

Date: Tue, Oct 10, 2023 17:02:33 IST
Location: United India Insurance Company Ltd
1/2 Reason: Signing Policy for UIIC
 MOTOR INSURANCE - MISCELLANEOUS AND SPECIAL TYPE OF VEHICLES-PACKAGE POLICY SCHEDULE
UIN. IRDAN545RP0049V01199900
Policy Number :2412003123P108075446 Previous Policy Number :
Geographical Area : India(A) Insurance Start Date & Time :11/10/2023 00:00 (hours)
Insured Name/ID : MR KUMAR SWAMI/23051341533 Insurance expiry Date & Time :10/10/2024 midnight
Insured address : Policy Issuing Office Address :
S/O SAKAPPA R/O KOMBHIHALLI KUDLIGI VIJAYANAGARA UMAMAHESWARA RAO BLDG, FLOOR NO:1, STATION ROAD, HOSPET, BELLARY, KARNATAKA - 583201
City: BELLARY District: BELLARY ,GST No.:- 29AAACU5552C1ZF
State: KARNATAKA Pincode: 583135 City: BELLARY District: BELLARY
Telephone: Mobile: 9741764858 State: KARNATAKA Pincode: 583201
Telephone:(08394) 229227,(08394) 228261
Business Channel Code:AGN1042406 Business Channel Sub Code:
Dealer Name: Agent Name: MOHAMMED GOUSE
Dealer Code: Land Line No.: ,Mobile:9880440256
VEHICLE DETAILS
Registration Number KA - 35 - TA - 2118 Obsolete Vehicle & No & 804123 Gross vehicle 1780
Chassis Number Weight
MASSY FERGUSON & MF 1035 Type Of Open/Agricultural Vehicles not
RTA Name KA35 HOSPET - 583201 Vehicle Make & Model
DI Body/Vehicle rateable under Agri Tractors
AA Membership
Registration Date 10/01/2013 Cubic Capacity 35
Name
Engine Number S3251E48458 Year Of Manufacture 2013 Geographical
Extension
INSURED DECLARED VALUE ( )
Co-
Vehicle Trailer Electrical/Electronic Accessories Non Electrical Accessories CNG Kit LPG Kit Total Insurance
Details
120000 45000 0 0 0 0 165000 100%
OTHER DETAILS
Unique
Financier Policy Subject to IMT Endorsements Applicable Addon-covers/Services
Reference Code
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
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) 12,650.00
Basic premium on Vehicle and Accessories B. Basic - TP 7,267.00
CGST(9%) 1,139.00
A. Basic - OD 2,100.00 Trailer - TP 2,485.00
SGST(9%) 1,139.00
Total 2,100.00 Total 9,752.00 TOTAL PAYABLE PREMIUM 14,928.00
Stamp Duty 1.00
Add : Add :
SAC Code 997134
Trailer- OD 472.50 Compulsory PA for Owner Driver 275.00 3123I108075446 &
Invoice No & Date
10/10/2023
LL to Paid Driver IMT 28 50.00 Receipt Number 10124120023109249681
Sub Total (Additions) 472.50 Receipt Date 10/10/2023
Receipt Amount 14,928.00
Sub Total (Additions) 325.00
Payment Mode
Gross OD(A) 2,573.00 Paying Party MR KUMAR SWAMI
Gross TP(B) 10,077.00

Gross OD & TP:

12,650.00
(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.
Underwriter Remarks: False

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 : 10/10/2023

In Witness Whereof this policy has been signed at DO HOSPET 241200 on this 10th day of October ,2023

For United India Insurance Company Limited

Affix Policy Stamp

Duly Constituted Attorneys

IP Address: 10.200.254.53
Issuing Agent: MOHAMMED GOUSE Printed By : MOHGOU86 @ 10/10/2023 5:03:11 PM Agent User Name: MOHGOU86
Underwritten By - MOHGOU86 ( INDIVIDUAL AGENT
Agent Location: 241200
ATTACHED TO DEVELOPMENT OFFICER )

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