UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
PRIVATE CAR-PACKAGE
UIN: IRDAN545RP0047V01199900
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 2507813121P110520678 Certificate Number 2507813121P110520678
Customer Id 23098842199 Issuing Office Address Code 250781
Name of the Insured MR ANIL YADAV MO OFFICE,361,SHAKTI NAGAR
8673,SHIDI PUR RAJ ENCLAVE KAROL BAGH NEW DELHI CHANDAUSI
202412
Address of the Insured CENTRAL DELHI MORADABAD
110005 UTTAR PRADESH
DELHI
Business/Occupation Others Telephone: Telephone (044) 28575255

Insured's Declared Value 464155

Period of Insurance From 00:00 Hrs of 15/01/2022 To Midnight of 14/01/2023

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)
MAHINDRA /
DL - 3C - AP - 4000 No HJB4M74511 MA1YL2HJUB6M65836 XUV500(2011 - SUV 2011 2179 7
2017) W8

Registration Authority Geographical Area Financier

Delhi - South - DL 03 INDIA
Amount in words: Thirteen thousand five 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: 11,021.00

The policy covers use of the vehicle for any purpose other than IGST(18%): 1,984.00
a) Hire or Reward
b) Carriage of Goods (other than samples or personal luggage) Stamp Duty: 1.00
c) Organized Racing Total (Rounded Off) : 13,005.00
d) Pace Making Receipt Number : 10125078121111854127
e) Speed Testing and Reliability Trails
Receipt Date: 13/01/2022
f) Use in connection with Motor Trade
DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: AGD0102304
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor NIKHILKUMAR , Mobile: 9456078986
Vehicles Act 1988 Dealer Name/Code:
Under Section II-I (ii) Damage to third party property in respect of any one claim or series of
claims arising out of one event 750000 Direct Business:
Development Officer Code:
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: 13/01/2022

Amount Subject to Reverse Charges-NIL
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.

This document is digitally signed

Signer: N MOHAN SANKAR

Date: Thu, Jan 13, 2022 16:57:47 IST
Location: United India Insurance Company Ltd
1/3 Reason: Signing Policy for UIIC
 MOTOR INSURANCE - PRIVATE CAR PACKAGE(UIN: IRDAN545RP0047V01199900) POLICY SCHEDULE
Policy Number :2507813121P110520678 Previous Policy No :2507813120P111691353
Geographical Area :India(A) Insurance Start Date & Time :15/01/2022 00:00 (hours)
Insured Name/ID : MR ANIL YADAV/23098842199 Insurance expiry Date & Time :14/01/2023 midnight
Insured address : Policy Issuing Office Address :
8673,SHIDI PUR RAJ ENCLAVE KAROL BAGH NEW DELHI MO OFFICE,361,SHAKTI NAGAR CHANDAUSI ,GST No.:- 09AAACU5552C1ZH
City: CENTRAL DELHI District: CENTRAL DELHI City: MORADABAD District: MORADABAD
State: DELHI Pincode: 110005 State: UTTAR PRADESH Pincode: 202412
Telephone: Mobile: 9899764707 Telephone:(044) 28575255
Business Channel Code:AGD0102304 Business Channel Sub Code:
Dealer Name: Agent Name:NIKHILKUMAR
Dealer Code: Land Line No.: ,Mobile:9456078986
VEHICLE DETAILS
Registration Number DL - 3C - AP - 4000 Obsolete Vehicle & Engine No & HJB4M74511 Year Of Manufacture 2011
Number Vehicle Weight(Kg.)
RTA Name Delhi - South - DL 03 Chassis Number MA1YL2HJUB6M65836 Cubic Capacity/KW 2179
MAHINDRA & XUV500(2011 - 2017)
Registration Date 21/01/2011 Vehicle Make & Model Type Of Body SUV
W8
AA Membership Number Geographical Extension Seating Capacity(Including 7
Driver)
INSURED DECLARED VALUE ( )
Co-
Vehicle Trailer Electrical/Electronic Accessories Non Electrical Accessories CNG Kit LPG Kit Total Insurance
Details
464155 0 0 0 0 0 464155 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) 11,021.00
Basic premium on Vehicle and Accessories B. Basic - TP 7,890.00
IGST(18%) 1,984.00
A. Basic - OD 5,012.02 Total 7,890.00
TOTAL PAYABLE PREMIUM 13,005.00
Total 5,012.02
Stamp Duty 1.00
Add :
SAC Code 997134
Compulsory PA for Owner Driver 275.00 3121I110520678 &
Invoice No & Date
13/01/2022
Less : PA for Unnamed persons
(No of persons: 6, SI per occupant: 300.00 Receipt Number 10125078121111854127
No Claim Bonus 50% 2,506.01 100000/-) Receipt Date 13/01/2022
Receipt Amount 13,005.00
Sub Total (Deductions) 2,506.01 LL to Paid Driver IMT 28 50.00
Payment Mode
Paying Party MR ANIL YADAV
Gross OD(A) 2,506.00 Sub Total (Additions) 625.00

Gross TP(B) 8,515.00

Gross OD & TP:

11,021.00
(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:13/01/2022

In Witness Whereof this policy has been signed at MO CHANDAUSI 250781 on this 13th day of January ,2022

For United India Insurance Company Limited

Affix Policy Stamp

Duly Constituted Attorneys

IP Address: 10.95.40.80
Issuing Agent: NIKHILKUMAR Printed By : CUSTOMER @ 13/01/2022 4:57:35 PM Agent User Name: NIKNIK001
Agent Location: 250781 Underwritten By - NIKNIK001 ( DIRECT AGENT )

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

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