UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
PRIVATE CAR -LIABILITY ONLY POLICY
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 1603053123P105191618 Certificate Number 1603053123P105191618
Customer Id 23235600930 Issuing Office Address Code 160305
Name of the Insured MR RAJENDRA BHUPAL KHOT 9TH LANE, SHRI. RAM MANDIR BUDILDING
A/P. KANADWADI, TAL. MIRAJ SUBHASH ROAD ,JAYSINGPUR
416101
Address of the Insured SANGLI KOLHAPUR
416306 MAHARASHTRA
MAHARASHTRA
Business/Occupation None Mobile No.- 8390018352 Telephone (2322) 228348
Insured's Declared Value 0

Period of Insurance From 00:00 Hrs of 11/08/2023 To Midnight of 10/08/2024

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)
MARUTI SUZUKI
MH - 43 - AN -
No K12MN1244194 MA3EHKD1S00422617 / SWIFT(2005 - HATCHBACK 2013 1197 5
2540
2014) VXI

Registration Authority Geographical Area Financier

MH43 NAVI MUMBAI RTO
INDIA
VASHI
Amount in words: Four thousand four hundred seventy-three 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.
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: 3,791.00
The policy covers use of the vehicle for any purpose other than
CGST(9%): 341.00
a) Hire or Reward
b) Carriage of Goods (other than samples or personal luggage) SGST(9%): 341.00
c) Organized Racing Stamp Duty: 1.00
d) Pace Making Total (Rounded Off) : 4,473.00
e) Speed Testing and Reliability Trails
Receipt Number : 10116030523106142998
f) Use in connection with Motor Trade
Receipt Date: 10/08/2023
DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: AGN1048592
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor VISHAL SURESH PATIL , Mobile: 7385761053
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 16,28
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: 10/08/2023

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.

This document is digitally signed

Signer: KALAIVENI SUBBIAH

Date: Thu, Aug 10, 2023 16:45:52 IST
Location: United India Insurance Company Ltd
1/3 Reason: Signing Policy for UIIC
 MOTOR INSURANCE - PRIVATE CAR LIABILITY ONLY POLICY SCHEDULE
Policy Number :1603053123P105191618 Previous Policy No :
Geographical Area :India(A) Insurance Start Date & Time :11/08/2023 00:00 (hours)
Insured Name/ID : MR RAJENDRA BHUPAL KHOT/23235600930 Insurance expiry Date & Time :10/08/2024 midnight
Insured address : Policy Issuing Office Address :
A/P. KANADWADI, TAL. MIRAJ 9TH LANE, SHRI. RAM MANDIR BUDILDING SUBHASH ROAD ,JAYSINGPUR ,GST No.:-
City: SANGLI District: SANGLI 27AAACU5552C1ZJ
State: MAHARASHTRA Pincode: 416306 City: KOLHAPUR District: KOLHAPUR
Telephone: Mobile: 8390018352 State: MAHARASHTRA Pincode: 416101
Telephone:(2322) 228348
Business Channel Code:AGN1048592 Business Channel Sub Code:
Dealer Name: Agent Name:VISHAL SURESH PATIL
Dealer Code: Land Line No.: ,Mobile:7385761053
VEHICLE DETAILS
Registration Number MH - 43 - AN - 2540 Obsolete Vehicle & Engine No & K12MN1244194 Year Of Manufacture 2013
Number Vehicle Weight(Kg.)
MH43 NAVI MUMBAI RTO
RTA Name Chassis Number MA3EHKD1S00422617 Cubic Capacity/KW 1197
VASHI
MARUTI SUZUKI & SWIFT(2005 -
Registration Date 22/04/2013 Vehicle Make & Model Type Of Body HATCHBACK
2014) VXI
AA Membership Number Geographical Extension Seating Capacity(Including 5
Driver)
INSURED DECLARED VALUE ( )
Co-
Vehicle Trailer Electrical/Electronic Accessories Non Electrical Accessories CNG Kit LPG Kit Total Insurance
Details
0 0 0 0 0 0 0 100%
OTHER DETAILS
Unique
Financier Policy Subject to IMT Endorsements Applicable Addon-covers/Services
Reference Code
16,28
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 1000 Imposed 0 Voluntary 0
(Under Section III)
SCHEDULE OF PREMIUM( )
A-OWN DAMAGE PREMIUM B-LIABILITY PREMIUM TOTAL PREMIUM
Premium(A+B) 3,791.00
B. Basic - TP 3,416.00
CGST(9%) 341.00
Total 3,416.00
SGST(9%) 341.00
Gross OD(A) 0.00 TOTAL PAYABLE PREMIUM
Add : 4,473.00
Stamp Duty 1.00
Compulsory PA for Owner Driver 275.00
SAC Code 997134
PA for Unnamed persons 3123I105191618 &
Invoice No & Date
(No of persons: 5, SI per occupant: 50.00 10/08/2023
20000/-) Receipt Number 10116030523106142998
Receipt Date 10/08/2023
LL to Paid Driver IMT 28 50.00
Receipt Amount 4,473.00
Payment Mode
Sub Total (Additions) 375.00 Paying Party MR RAJENDRA BHUPAL
KHOT

Gross TP(B) 3,791.00

Total Liability Premium 3,791.00

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:10/08/2023

In Witness Whereof this policy has been signed at BO JAYSINPUR 160305 on this 10th day of August ,2023

For United India Insurance Company Limited

Affix Policy Stamp

Duly Constituted Attorneys

IP Address: 10.95.40.80
Issuing Agent: VISHAL SURESH PATIL Printed By : CUSTOMER @ 10/08/2023 4:45:14 PM Agent User Name: KAM19914
Agent Location: 160305 Underwritten By - KAM19914 ( BO UW CUM CASHIER )

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