UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
TWO WHEELER-1 YEAR OWN DAMAGE COVER BUNDLED WITH 5 YEARS LIABILITY COVER
UIN: IRDAN545RP0011V01201819
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 0402013124P121194728 Certificate Number 0402013124P121194728
Customer Id 23409331758 Issuing Office Address Code 040201
IST FLOOR, UDYOG NAGAR METRO STATION, NEAR PEERAGARI, NEW DELHI
Name of the Insured MR RAM SAGAR
NADAN, NADAN, MAHOLI
110041
WEST DELHI
Address of the Insured 261141
DELHI
SITAPUR
Telephone (9111) 25251995
UTTAR PRADESH
Business/Occupation Others Mobile No.- ******9076
Insured's Declared Value 39990

Own Damage From 18:50 Hrs of 31/03/2025 To Midnight of 30/03/2026

Period of Insurance
Liability From 18:50 Hrs of 31/03/2025 To Midnight of 30/03/2030
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)
AP2BS2301966 MD621BP27S3B05818 Solo with Pillion
NEW No TVS / XL HEAVY DUTY HD 2025 100 2

Registration Authority Geographical Area Financier

UP34 SITAPUR INDIA INDUSIND BANK LTD(LUCKNOW..,LUCKNOW,UTTAR PRADESH-226001)
Amount in words: Four thousand seven hundred two 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.
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: 3,985.00
The policy covers use of the vehicle for any purpose other than IGST(18%): 717.00
a) Hire or Reward
Stamp Duty: 1.00
b) Carriage Goods (other than samples or personal luggage)
c) Organized Racing Total(Rounded Off): 4,702.00
d) Pace Making Receipt Number : 10104020124125063955
e) Speed Testing and Reliability Trials Receipt Date: 31/03/2025
f) Use in connection with Motor Trade DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: BRC1450905
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor GIRNAR INSURANCE BROKERS PVT
Vehicles Act 1988 LTD_244 , Mobile: 7551196989
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: 100000 /-
Direct Business:
Development Officer Code:
Subject to IMT Endorsement No.s, terms and conditions printed herein / attached hereto 7,22
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.
Date of Issue: 31/03/2025
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. For and On behalf of
United India Insurance Co. Ltd.
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.
Duly Constituted Attorney

This document is digitally signed

Signer: DS UNITED INDIA INSURANCE CO LTD 1

Date: Mon, Mar 31, 2025 18:52:46 IST
Location: United India Insurance Company Ltd
1/2 Reason: Signing Policy for UIIC by Harmeet Singh Chahal
 MOTOR INSURANCE - TWO WHEELER-1 YEAR OWN DAMAGE COVER BUNDLED WITH 5 YEARS LIABILITY COVER(UIN:
IRDAN545RP0011V01201819) POLICY SCHEDULE
Policy Number :0402013124P121194728 Previous Policy No :
:From 18:50 Hrs of 31/03/2025 To Midnight of
Geographical Area :India(A) Period of Insurance(Own Damage)
30/03/2026
:From 18:50 Hrs of 31/03/2025 To Midnight of
Insured Name/ID : MR RAM SAGAR/23409331758 Period of Insurance(Liability)
30/03/2030
Insured address : Policy Issuing Office Address :
NADAN, NADAN, MAHOLI IST FLOOR, UDYOG NAGAR METRO STATION, NEAR PEERAGARI, NEW DELHI ,GST No.:-
City: SITAPUR District: SITAPUR 07AAACU5552C1ZL
State: UTTAR PRADESH Pincode: 261141 City: WEST DELHI District: WEST DELHI
Telephone: Mobile: ******9076 State: DELHI Pincode: 110041
Telephone:(9111) 25251995
Business Channel Code: BRC1450905 Business Channel Sub Code:
Dealer Name: Agent Name:GIRNAR INSURANCE BROKERS PVT LTD_244
Dealer Code: Land Line No: ,Mobile:7551196989
VEHICLE DETAILS
Obsolete Vehicle & Engine Year Of
Registration Number NEW No & AP2BS2301966 2025
Number Manufacture
RTA Name UP34 SITAPUR Chassis Number MD621BP27S3B05818 Cubic Capacity/KW 100
TVS & XL HEAVY DUTY
Registration Date 31/03/2025 Vehicle Make & Model Type Of Body Solo with Pillion
HD
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
39990 0 0 0 0 0 39990 100%
OTHER DETAILS
Unique
Financier Policy Subject to IMT Endorsements Applicable Addon-covers/Services
Reference Code
INDUSIND BANK LTD(LUCKNOW..,LUCKNOW,UTTAR PRADESH-226001) 7,22
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
0 Compulsory 100 Imposed 0 Voluntary 0
(Under Section III)
SCHEDULE OF PREMIUM ( )
A-OWN DAMAGE PREMIUM B-LIABILITY PREMIUM
TOTAL PREMIUM
(From 31/03/2025 To 30/03/2026) (From 31/03/2025 To 30/03/2030)
Premium(A+B) 3,985.00
Basic premium on Vehicle and Accessories B. Basic TP 3,851.00
IGST(18%) 717.00
A. Basic OD 134.05 Total 3,851.00 TOTAL PAYABLE PREMIUM 4,702.00
Total 134.05 Stamp Duty 1.00
SAC Code 997134
3124I121194728 &
Invoice No & Date
Gross TP(B) 3,851.00 31/03/2025
Receipt Number 10104020124125063955
Gross OD & TP: Receipt Date 31/03/2025
Gross OD(A) 134.00 3,985.00
(A) + (B)
Receipt Amount 4,702.00
Payment Mode
Paying Party MR RAM SAGAR
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 : 31/03/2025

In Witness Whereof this policy has been signed at BO 2 NEW DELHI 040201 on this 31st day of March ,2025

For United India Insurance Company Limited

Affix Policy Stamp

Duly Constituted Attorneys

IP Address: 10.95.40.80
GIRNAR INSURANCE
Issuing Agent: Printed By : CUSTOMER @ 31/03/2025 6:52:44 PM Agent User Name: GIRLTD0044
BROKERS PVT LTD_244
Agent Location: 040201 Underwritten By - GIRLTD0044 ( BROKER )

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

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