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. 1417023125P107458689 Certificate Number 1417023125P107458689
Customer Id Issuing Office Address Code 141702
23322874097
Name of the Insured MR SURESH GURJAR ABOVE HDFC BANK, NEAR OLD BUS STAND,
BEHROR, ALWAR, RAJASTHAN
RAMBABU RAYPURA KI DHAL KISHORI
301713
ALWAR
Address of the Insured 301022
RAJASTHAN
ALWAR
Telephone (1494) 220008
RAJASTHAN
Business/Occupation Others Mobile No.- ******8647
Insured's Declared Value 123519

Own Damage From 11:01 Hrs of 08/08/2025 To Midnight of 07/08/2026

Period of Insurance Liability From 11:01 Hrs of 08/08/2025 To Midnight of 07/08/2030
CPA Cover From 11:01 Hrs of 08/08/2025 To Midnight of 07/08/2026
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)
CE8FS2X23892 MD634BE85S2F24677 TVS / APACHE 160 2V RM DISC BT Solo with Pillion
NEW No 2025 160 2
null
Registration Authority Geographical Area Financier
RJ02 ALWAR INDIA SHRIRAM FINANCE LIMITED(ALWAR,ALWAR,RAJASTHAN-301406)
Amount in words: Nine thousand seven hundred eighty-four 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: 8,292.00
The policy covers use of the vehicle for any purpose other than CGST(9%): 746.00
a) Hire or Reward
SGST(9%): 746.00
b) Carriage Goods (other than samples or personal luggage)
c) Organized Racing Stamp Duty: 1.00
d) Pace Making Total(Rounded Off): 9,784.00
e) Speed Testing and Reliability Trials Receipt Number : 10114170225109705293
f) Use in connection with Motor Trade Receipt Date: 08/08/2025
DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: BRC0001039000001752
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor POLICYBAZAAR INSURANCE
Vehicles Act 1988 BROKERS_2752 , Mobile:
Under Section II-I (ii) Damage to third party property in respect of any one claim or series of 1111011110
claims arising out of one event: 100000 /- Dealer Name/Code:

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: 08/08/2025
For and On behalf of
Amount Subject to Reverse Charges-NIL
United India Insurance Co. Ltd.
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: Fri, Aug 8, 2025 11:06:12 IST
Location: United India Insurance Company Ltd
1/3 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 :1417023125P107458689 Previous Policy No :
:From 11:01 Hrs of 08/08/2025 To Midnight of
Geographical Area :India(A) Period of Insurance(Own Damage)
07/08/2026
:From 11:01 Hrs of 08/08/2025 To Midnight of
Period of Insurance(Liability) 07/08/2030
Insured Name/ID : MR SURESH GURJAR/23322874097
Period of Insurance(CPA) :From 11:01 Hrs of 08/08/2025 To Midnight of
07/08/2026
Insured address : Policy Issuing Office Address :
RAMBABU RAYPURA KI DHAL KISHORI ABOVE HDFC BANK, NEAR OLD BUS STAND, BEHROR, ALWAR, RAJASTHAN ,GST No.:-
City: ALWAR District: ALWAR 08AAACU5552C1ZJ
State: RAJASTHAN Pincode: 301022 City: ALWAR District: ALWAR
Telephone: Mobile: ******8647 State: RAJASTHAN Pincode: 301713
Telephone:(1494) 220008
Business Channel Code: BRC0001039000001752 Business Channel Sub Code:
Dealer Name: Agent Name:POLICYBAZAAR INSURANCE BROKERS_2752
Dealer Code: Land Line No:1800 2585970,Mobile:1111011110
VEHICLE DETAILS
Obsolete Vehicle & Engine Year Of
Registration Number NEW No & CE8FS2X23892 2025
Number Manufacture
RTA Name RJ02 ALWAR Chassis Number MD634BE85S2F24677 Cubic Capacity/KW 160
TVS & APACHE 160 2V RM
Registration Date 08/08/2025 Vehicle Make & Model Type Of Body Solo with Pillion
DISC BT null
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
123519 0 0 0 0 0 123519 100%
OTHER DETAILS
Unique
Financier Policy Subject to IMT Endorsements Applicable Addon-covers/Services
Reference Code
SHRIRAM FINANCE LIMITED(ALWAR,ALWAR,RAJASTHAN-301406) 7,22 Nil Depreciation Without Excess
PERSONS OR CLASS OF PERSONS ENTITLED TO DRIVE:As narrated in the certificate of insurance attached herewith. Name Of the CPA Nominee Relation Age Name of the Appointee
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. RAMBABU Father NA
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 III)
SCHEDULE OF PREMIUM ( )
A-OWN DAMAGE PREMIUM B-LIABILITY PREMIUM
TOTAL PREMIUM
(From 08/08/2025 To 07/08/2026) (From 08/08/2025 To 07/08/2030)
Premium(A+B) 8,292.00
Basic premium on Vehicle and Accessories B. Basic TP 7,365.00
CGST(9%) 746.00
A. Basic OD 434.79 Total 7,365.00 SGST(9%) 746.00
Total 434.79 TOTAL PAYABLE PREMIUM 9,784.00
Add :
Stamp Duty 1.00
Compulsory PA for Owner Driver SAC Code 997134
Add : 275.00
(From 08/08/2025 To 07/08/2026) 3125I107458689 &
Invoice No & Date
Nil Depreciation Without Excess 217.39 08/08/2025
Receipt Number 10114170225109705293
Sub Total (Additions) 275.00 Receipt Date 08/08/2025
Sub Total (Additions) 217.39
Receipt Amount 9,784.00
Payment Mode
Gross TP(B) 7,640.00
Paying Party MR SURESH GURJAR
Gross OD(A) 652.00 Gross OD & TP:
8,292.00
(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 : 08/08/2025

In Witness Whereof this policy has been signed at BO BEHROR 141702 on this 08th day of August ,2025

For United India Insurance Company Limited

Affix Policy Stamp

Duly Constituted Attorneys

IP Address: 10.95.40.81
POLICYBAZAAR INSURANCE
Issuing Agent: Printed By : CUSTOMER @ 08/08/2025 11:06:11 AM Agent User Name: POLBRO002293
BROKERS_2752
Agent Location: 141702 Underwritten By - POLBRO002293 ( BROKER )

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