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Tollfree numbers Claims : 1800 258 5881

MOTOR INSURANCE ‐ PRIVATE CAR PACKAGE POLICY SCHEDULE

Policy Number :22300031250160126681 Previous Policy Number :0516033123P111272145

Geographical Area :India Insurance Start Date & Time :04‐02‐2025 00:00﴾hours﴿
Insured Name :Mr POTHULA SAINATH Insurance Expiry Date & Time :03‐02‐2026 Midnight
Insured Address : Policy Issuing Office Address :

Divisional Office‐30 ﴾Gurugram﴿ Unit no: 34,35,6A,6B,Ground Floor,

Nayanacheruvupalli,Mulakalacheruvu mandal,Anamaya district
Vipul Trade Centre, Sector‐48, Sohna Road,
City :CHITTOOR
City :Gurugram District :Gurugram
State :ANDHRA PRADESH Pincode :517390
State :Haryana Pincode :122001
Mobile No :9100433575 GSTIN :
Office Contact Details :0124‐2213170 Email ID :[email protected]
Email :[email protected]
Fax : GSTIN :06AAACU5552C1ZN

Business Channel Code: NA Business Channel Sub Code: BRC0001039

M/S POLICYBAZAAR INSURANCE BROKERS PRIVATE
Mobile No.: 18002585970 ﴾Service﴿ , 18002585881 ﴾Claims﴿ Broker Name :
LIMITED
IRDA License Number: IRDA/ DB 797/ 19

VEHICLE DETAILS
Year of Manufacture Vehicle
Registration Number AP‐27‐AY‐9999 Engine Number 1KDU740141 2015
Weight﴾kg.﴿
RTA Name AP27 Prakasam Chassis Number MBJ11JV61040410370315 Cubic Capacity / GVW / KWH 2982
Registration Date 28/05/2015 Vehicle Make & Model TOYOTA ‐ FORTUNER ‐ 3.0 4X2 MT Type of Body ‐
AA Membership Name Seating Capacity 7 Geographical Extension

INSURED DECLARED VALUE ﴾IN RUPEES﴿

Electrical /Electronic Non‐Electrical Co‐Insurance
Vehicle Trailer FiberGlass CNG Kit LPG Kit TOTAL
Accessories Accessories Details
882,000.00 0 0 0 0 0.00 0.00 882,000.00 0.00

OTHER DETAILS
Financier Branch Name & Address Policy Subject to IMT Endorsements/Applicable covers

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.

OTHER DETAILS
EXCLUSIONS: ﴾1﴿ Any accidental loss or damage and/or liability 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 or liability directly or indirectly or proximately or remotely occasioned
by 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 consequence 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 ﴾In Rupees﴿ DEDUCTIBLES ﴾Under Section I﴿ ﴾In Rupees﴿
Owner‐ Driver ﴾Under section IV﴿ 0 Compulsory 2,000.00 Imposed 0 Voluntary 0.00

SCHEDULE OF PREMIUM ﴾IN RUPEES﴿

A‐OWN DAMAGE PREMIUM B‐LIABILITY PREMIUM TOTAL PACKAGE PREMIUM
Basic Own Damage 30,958.00 Basic TP Liability 7,897.00 Package Premium 12,541.00
Sub Total﴾Additions﴿ 0.00 PA Owner Driver 0.00 GST @18.00% 2,257.00
Sub Total ﴾Deductions﴿ 26,314.00 Sub Total ﴾Additions﴿ 0.00 TOTAL PAYABLE PREMIUM 14,798.00
Total 4,644.00 Sub Total ﴾Deductions﴿ 0 Stamp Duty Rs. 1
Total 7,897.00 Receipt Date 03/02/2025
Receipt Amount 14,798.00
Payment Mode Online
Paying Party M/S KISHORE STONES

CHEQUE DETAIL
Cheque Number Cheque Date Bank Name Branch Name Branch Code Cheque Signatory MICR No
PB117131923 03/02/2025 Bank Name CC M/S KISHORE STONES

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 http://uiic.co.in/sites/default/files/uploads/downloadcenter/IndianMotorTariff.pdf.
For terms and conditions for add on covers go to : http://uiic.co.in/sites/default/files/uploads/downloadcenter/motor_additional_covers.pdf
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 from 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. Date & Signature of Proposal: 03/02/2025 00:00:00.0
In Witness whereof this Policy has been signed at GURGAON this day of , Date
For United India Insurance Company Limited

CONSOLIDATED STAMP DUTY PAID VIDE

GRN NO. 75907349 DTD 31/03/2021
ISSUED BY TREASURY OFFICER, GURGAON

Duly Constituted Attorneys

IP Address: 10.80.25.162
Print Date: 03/02/2025 10:39:01hours
United India Insurance Company Ltd : IRDA Reg: No : 545
Policy Schedule generated by Policy Bazaar on 03‐02‐2025 10:39:01hours
* This is a system generated document and any manual alteration / correction / overwriting in the document will make it invalid.
"IN CASE OF CLAIM KINDLY CONTACT OUR NEAREST LOCAL OFFICE".