UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
MOTORCYCLE / SCOOTER - LIABILITY ONLY POLICY
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 1119033124P114979209 Certificate Number 1119033124P114979209
Customer Id 23371804871 Issuing Office Address Code 111903
SHOP NO. 75,
Name of the Insured MR SHAMSHER SINGH SON OF SANTOKH SINGH
FIRST FLOOR, ANAJ MANDI,
765 C NEAR SCHOOL VILLAGE DHANI SADHAWALI JIWAN NAGAR
125050
SIRSA
FATEHABAD
Address of the Insured HARYANA
125075
Telephone (01667) 220589,(01667) 221198
SIRSA
HARYANA
Business/Occupation Others Mobile No.- 9811111111
Insured's Declared Value 0

Period of Insurance From 16:53 Hrs of 22/12/2024 To Midnight of 21/12/2025

Particulars of Vehicle Insured
Registration No.
Trailer Cubic Seating including
Obsolete Vehicle Engine No. Chassis No. Make/Model Type of Body Year of Mfg
Vehicle (if Capacity/KW driver
any)
HR - 44 - C - DUUBSH55522 MD2DDDZZZSPH52131 BAJAJ AUTO LTD / PLATINA 100 Solo with Pillion
No 2010 100.00 2
7818 ALLOY ES BS6
Registration Authority Geographical Area Financier
HR44 ELLENABAD INDIA
Amount in words: Eight hundred forty-two 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: 714.00
The policy covers use of the vehicle for any purpose other than CGST(9%): 64.00
a) Hire or Reward
SGST(9%): 64.00
b) Carriage Goods (other than samples or personal luggage)
c) Organized Racing Stamp Duty: 1.00
d) Pace Making Total(Rounded Off): 842.00
e) Speed Testing and Reliability Trials Receipt Number : 10111190324117542202
f) Use in connection with Motor Trade Receipt Date: 22/12/2024
DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: AGN1049715
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor KALPANA RANI , Mobile:
Vehicles Act 1988 8198955128
Under Section II-I (ii) Damage to third party property in respect of any one claim or series of Dealer Name/Code:
claims arising out of one event: 100000 /-
Direct Business: BD49341
BDIS Code:
ANCHAL BHARTI
Subject to IMT Endorsement No.s, terms and conditions printed herein / attached hereto
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: 22/12/2024
Note:-With reference to IRDAI circular no IRDAI/NL/CIR/MOTP/170/10/2018 dated 09/10/2018 and as
per the declaration given in the proposal form by owner driver Compulsory Personal Accident (CPA) cover is
removed, since he/she is not holding a valid driving license. For and On behalf of
United India Insurance Co. Ltd.

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.
Duly Constituted Attorney

This document is digitally signed

Signer: DS UNITED INDIA INSURANCE CO LTD 1

Date: Sun, Dec 22, 2024 16:54:56 IST
Location: United India Insurance Company Ltd
1/2 Reason: Signing Policy for UIIC by Harmeet Singh Chahal
 MOTOR INSURANCE - MOTORCYCLE / SCOOTER - LIABILITY ONLY POLICY SCHEDULE
Policy Number :1119033124P114979209 Previous Policy No :
Geographical Area :India(A) Insurance Start Date & Time :22/12/2024 16:53 (hours)
: MR SHAMSHER SINGH SON OF SANTOKH
Insured Name/ID Insurance expiry Date & Time :21/12/2025 midnight
SINGH/23371804871
Insured address : Policy Issuing Office Address :
765 C NEAR SCHOOL VILLAGE DHANI SADHAWALI JIWAN NAGAR SIRSA SHOP NO. 75, FIRST FLOOR, ANAJ MANDI, ,GST No.:- 06AAACU5552C1ZN
City: SIRSA District: SIRSA City: FATEHABAD District: FATEHABAD
State: HARYANA Pincode: 125075 State: HARYANA Pincode: 125050
Telephone: Mobile: 9811111111 Telephone:(01667) 220589,(01667) 221198
Business Channel Code: AGN1049715 Business Channel Sub Code:
Dealer Name: Agent Name:KALPANA RANI
Dealer Code: Land Line No: ,Mobile:8198955128
VEHICLE DETAILS
Obsolete Vehicle & Engine Year Of
Registration Number HR - 44 - C - 7818 No & DUUBSH55522 2010
Number Manufacture
RTA Name HR44 ELLENABAD Chassis Number MD2DDDZZZSPH52131 Cubic Capacity/KW 100.00
BAJAJ AUTO LTD &
Registration Date 12/03/2010 Vehicle Make & Model PLATINA 100 ALLOY ES Type Of Body Solo with Pillion
BS6
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
0 0 0 0 0 0 0 100%
OTHER DETAILS
Unique
Financier Policy Subject to IMT Endorsements Applicable Addon-covers/Services
Reference Code

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 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
0 Compulsory 100 Imposed 0 Voluntary 0
(Under Section III)
SCHEDULE OF PREMIUM ( )
A-OWN DAMAGE PREMIUM B-LIABILITY PREMIUM TOTAL PREMIUM
Premium(A+B) 714.00
B. Basic TP 714.00
CGST(9%) 64.00
Total 714.00 SGST(9%) 64.00
Gross OD(A) 0.00 TOTAL PAYABLE PREMIUM 842.00
Stamp Duty 1.00
SAC Code 997134
Gross TP(B) 714.00 3124I114979209 &
Invoice No & Date
22/12/2024
Total Liability Premium 714.00
Receipt Number 10111190324117542202
Receipt Date 22/12/2024
Receipt Amount 842.00
Payment Mode
MR SHAMSHER SINGH
Paying Party
SON OF SANTOKH SINGH
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 : 22/12/2024

In Witness Whereof this policy has been signed at BO FATEHABAD 111903 on this 22nd day of December ,2024

For United India Insurance Company Limited

Affix Policy Stamp

Duly Constituted Attorneys

IP Address: 10.95.40.80
Issuing Agent: KALPANA RANI Printed By : CUSTOMER @ 22/12/2024 4:54:54 PM Agent User Name: KALRAN91
Agent Location: 111903 Underwritten By - KALRAN91 ( 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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