UNITED INDIA INSURANCE COMPANY LIMITED

ROHIT CHAMBERS JANMBHOOMI MARG, FORT MUMBAI, MUMBAI, MAHARASTRA

GREATER MUMBAI - 400001 MAHARASHTRA
PH: (022) 22838778 FAX: EMAIL:

PRIVATE CAR-1 YEAR OWN DAMAGE COVER BUNDLED WITH 3 YEARS LIABILITY
COVER
UIN: IRDAN545RP0012V01201819
POLICY NO.:0209003121P105184644
VEHICLE NO.:NEW

PERIOD OF INSURANCE
Own Damage:From 17:35 Hrs of 30/08/2021 To Midnight of 29/08/2022
Liability:From 17:35 Hrs of 30/08/2021 To Midnight of 29/08/2024
CPA Cover:From 17:35 Hrs of 30/08/2021 To Midnight of 29/08/2024

Insured
MR SUMIT KUMAR
S/O SHRI JEETENDRA PRASAD1 SMQ 40 WING AIR FORCE STATION MAHARAJPURAGWALIOR
M.P

474001
GWALIOR
MADHYA PRADESH
CONTACT NUMBER: 8168910753 (M)
IMPORTANT NOTICE: KINDLY UPDATE YOUR AADHAAR NO. AND PAN/FORM 60. PLEASE IGNORE IF ALREADY UPDATED.

MISP Name/Code : TATA MOTORS/MISP000927

1800209006 / (22) 66207922
Mobile/Landline Number/Email :
amol.jawharkar@tatamotorsinsurancebrokers.com
Designated Person Name : TATA MOTORS MISP
TATA MOTORS INSURANCE BROKING &
Intermediary Name/Code :
ADVISORY SERVICES LTD./BRC0000263

The genuineness of the policy can be verified through "Verify Your Policy" link at www.uiic.co.in.

For any Information, Service Requests, Claim intimation and Grievances please write to 020900@uiic.co.in

Download Customer App(www.uiic.co.in). REGD. & HEAD OFFICE, 24, WHITES ROAD, CHENNAI - 600014.
Website: http://www.uiic.co.in
Printed By : CUSTOMER @ 31/08/2021 10:22:08 AM

This document is digitally signed

Signer: N MOHAN SANKAR

Date: Tue, Aug 31, 2021 10:22:13 IST
Location: United India Insurance Company Ltd
1/4 Reason: Signing Policy for UIIC
 UNITED INDIA INSURANCE COMPANY LIMITED
CERTIFICATE OF INSURANCE
PRIVATE CAR-1 YEAR OWN DAMAGE COVER BUNDLED WITH 3 YEARS LIABILITY COVER
UIN: IRDAN545RP0012V01201819
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 0209003121P105184644 Certificate Number 0209003121P105184644
Customer Id 23116076537
Name of the Insured MR SUMIT KUMAR Issuing Office Address C o d e 020900
S/O SHRI JEETENDRA PRASAD1 SMQ 40 WING ROHIT CHAMBERS JANMBHOOMI MARG, FORT MUMBAI, MUMBAI,
Address of the Insured AIR FORCE STATION MAHARAJPURAGWALIOR MAHARASTRA 400001 GREATER MUMBAI MAHARASHTRA
M.P 474001 GWALIOR MADHYA PRADESH
Business/Occupation Others Telephone: Telephone (022) 22838778

Insured's Declared Value 657875

Own Damage From 17:35 Hrs of 30/08/2021 To Midnight of 29/08/2022

Period of Insurance Liability From 17:35 Hrs of 30/08/2021 To Midnight of 29/08/2024
CPA Cover From 17:35 Hrs of 30/08/2021 To Midnight of 29/08/2024
Particulars of Vehicle Insured
Registration No. Make/ Seating
Obsolete Type of Year of Cubic
Trailer Engine No. Chassis No. Model including
Vehicle Vehicle Body Mfg Capacity/KW
( if any) Model driver
Tata /
REVTRN11EYXK47858 MAT627223MLE34259 NEXON
NEW No Sedan 2021 1198 5
NEXON (P)
XE
Registration Authority Geographical Area
ZONE B RTO INDIA
Amount in words: Twenty-nine thousand eight hundred nineteen 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: 25,270.00
The policy covers use of the vehicle for any purpose other than IGST(18%): 4,549.00
a) Hire or Reward Stamp Duty: 1.00
b) Carriage of Goods (other than samples or personal luggage) Total (Rounded Off) : 29,819.00
c) Organized Racing Receipt Number : 10102090021105473390
d) Pace Making Receipt Date: 30/08/2021
e) Speed Testing and Reliability Trails
DebitNote Number:
f) Use in connection with Motor Trade
Document Date:
Limits of Liability MISP Code: MISP000927
Under Section II-I (i) Death or bodily injury in respect of any one TATA MOTORS
accident; As per Motor Vehicles Act 1988 Direct Business:
Under Section II-I (ii) Damage to third party property in respect of Development Officer Code:
any one claim or series of claims arising out of one event:
750000
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 For and On behalf of
the certificate of insurance are issued in accordance with provisions of United India Insurance Co. Ltd.
Chapter X & XI of M.V Act, 1988.

Duly Constituted Attorney:

Date of Issue: 30/08/2021
Policy No: 0209003121P105184644

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 Policy No: 0209003121P105184644

PRIVATE CAR-1 YEAR OWN DAMAGE COVER BUNDLED WITH 3 YEARS LIABILITY COVER
UIN: IRDAN545RP0012V01201819

Policy No. 0209003121P105184644 Previous Policy No.

Customer Id 23116076537
Insured Details Name MR SUMIT KUMAR
Fax: 0
Tel (O) Tel (R)
Mobile: 8168910753
Email NIL@GMAIL.COM
Business / Occupation Others
Own Damage From 17:35 Hrs of 30/08/2021 To Midnight of 29/08/2022
Period of Insurance Liability From 17:35 Hrs of 30/08/2021 To Midnight of 29/08/2024
CPA Cover From 17:35 Hrs of 30/08/2021 To Midnight of 29/08/2024

Company Name Office Code Leader(L)/Non-Leader(N) Share(%)

Co-Insurance Type Outgoing
UIIC 020900 L 20
UIIC 190800 N 80

Particulars of Vehicle Insured

Registration Obsolete Engine No. Chassis No. M a k e / Model Model Year of Type of Cubic Seating
No. Vehicle Mfg Body Capacity/KW including driver
Vehicle Trailer
( if
any)
Tata / NEXON
NEW No 2021 Sedan 1198 5
REVTRN11EYXK47858 MAT627223MLE34259 NEXON (P) XE
Insured's Declared Value
For Vehicle For Trailer Non Electrical Accessories Electrical/Electronic Accessories CNG Unit LPG Unit Total Value

657875 0 0 0 0 0 657875
Registration
Auto Association Membership No. Geographical Area Extension
Authority
ZONE B RTO INDIA
Amount in words: Twenty-nine thousand eight hundred nineteen rupees only
Persons or classes of persons entitled to drive 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
The Policy covers use of the Vehicle for any purpose other than
a) Hire or Reward
b) Carriage of Goods (other than samples or personal luggage)
c) Organized Racing
d) Pace Making
e) Speed Testing and Reliability Trails
f) Use in connection with Motor Trade
Limits of Liability As narrated in the Certificate of Insurance attached herewith.
EXCLUSIONS :
1) Any accidental loss or damage or Liability / caused or sustained or incurrred 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 any expense whatsoever resulting or arising there from or any
consequential loss.
4) Any liability of whatsoever nature directly or indirectly caused by or constituted to or by or 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 proximatley or remotely occasioned by contributed to, by or traceable to
or arising out of or in connection with war, invasion, 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 consequence of any of the said
occurrences or nay consequence thereof and in default of such proof, the Company shall not be liable to make any payment in respect of
such a claim.
Personal Accident covers for Owner-Driver CSI: 1500000
This policy is subject to terms and conditions and IMT Endorsement Nos. printed herein/ attached hereto 16,22,28
Imposed Excess 0
Voluntary Excess 0
Compulsory Excess 1000

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 SCHEDULE OF PREMIUM (IN )
OWN DAMAGE LIABILITY
(From 30/08/2021 To 29/08/2022) (From 30/08/2021 To 29/08/2024)

Basic premium on Vehicle and Accessories

B. Basic - TP 9,534.00
A. Basic - OD 8,187.19
Total 9,534.00
Total 8,187.19

Add :
Add :
Compulsory PA for Owner Driver
Portal Loading 2,002.00 705.00
(From 30/08/2021 To 29/08/2024)

Add : PA for Unnamed persons 750.00

Nil Depreciation Without Excess 2,099.28 LL to Paid Driver IMT 28 150.00

Return to Invoice 986.81

Sub Total (Additions) 1,605.00
Engine and Gearbox Protection Platinum Add
855.24
On Cover
Gross TP(B) 11,139.00
Sub Total (Additions) 5,943.33
Gross OD & TP:
25,270.00
(A) + (B)

Gross OD(A) 14,131.00

TERMS AND 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 UIIC website : www.uiic.co.in
Disclaimer : T h e Policy stands cancelled or void in the event of Cheque Dishonor. The Company may cancel the policy by sending 7 days
notice in case of any fraud or misrepresentation, non-disclosure 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 M O T O R
VEHICLES ACT, 1988 IS RECOVERABLE FROM THE INSURED. SEE THE CLAUSE HEADED "AVOIDANCE OF CERTAIN TERMS AND R I G H T O F
RECOVERY" . FOR LEGAL INTERPRETATION, ENGLISH VERSION WILL HOLD GOOD.

Premium 25,270.00 Receipt MISP Code: MISP000927

Number 10102090021105473390 TATA MOTORS
Receipt 30/08/2021Direct Business:
IGST(18%): 4,549.00
Date
DebitNote
Stamp Duty 1.00 Development Officer Code:
Number

Document
Total (Rounded Off) 29,819.00
Date

Customer GST/UIN No.: Office GST No.: 27AAACU5552C1ZJ

SAC Code: 997134 Invoice No. & Date: 3121I105184644 & 30/08/2021
Amount Subject to Reverse Charges-NIL

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 of Proposal and Declaration: 30/08/2021

IN WITNESS WHEREOF, this policy has been signed at DO 9 MUMBAI 020900 on this 30th day of August 2021.

For and On behalf of

United India Insurance Co. Ltd.

Affix Policy
Stamp here.

Duly Constituted Attorney:

Underwritten By - TATAMOTORS ( OEMUSER )

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

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