MOTOR INSURANCE ‐ PRIVATE CAR PACKAGE POLICY SCHEDULE

Policy Number 1404603125P150980120 Previous Policy Number :ABC123

Geographical Area :India Insurance Start Date & Time :28‐08‐2025 00:00(hours)
Insured Name :MR.SARDAR SINGH Insurance Expiry Date & Time :27‐08‐2026 Midnight
Insured Address : Policy Issuing Office Address :

VPO: 2869, GHEEWALON Divisional Office‐30 (Gurugram) Unit no: 34,35,6A,6B,Ground Floor,
KA RASTA 5TH CROSS Vipul Trade Centre, Sector‐48, Sohna Road,
JOHARI BAZAR City :Gurugram District :Gurugram
District :JAIPUR
State :Haryana Pincode :122001
City :JAIPUR
Office Contact Details :7338829307 Email ID :pb.support@uiic.co.in
State :RAJASTHAN Pincode :302001 Fax : GSTIN :06AAACU5552C1ZN
Mobile No :9784681691
Email :suleman.girik@gmail.com

Business Channel Code: NA Business Channel Sub Code: BRC0001039

Mobile No.: 18002585970 (Service) Agent Name : Policybazaar Insurance Broker Pvt. Ltd
IRDA License Number: IRDAI/WBA21/15‐06

VEHICLE DETAILS
Year of Manufacture Vehicle
Registration Number RJ45‐UA‐0089 Engine Number HJD4B20737 2013
Weight(kg.)
RTA Name RJ45 JAIPUR Chassis Number D6B18345 Cubic Capacity / GVW 2179
Registration Date 21/03/2013 Vehicle Make & Model MAHINDRA & XUV 500 W8 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
340,000.00 0 0 0 0 0.00 0.00 340,000.00 0.00

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

NOMINEE DETAILS
Nominee Name Nominee Relationship Nominee Age
ADITYA SON 27

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) 15,00,000.00 Compulsory 1,000.00 Imposed 0 Voluntary 0.00

SCHEDULE OF PREMIUM (IN RUPEES)

A‐OWN DAMAGE PREMIUM B‐LIABILITY PREMIUM TOTAL PACKAGE PREMIUM
Basic Own Damage 33,539.00 Basic TP Liability 3,416.00 Package Premium 8,817.00
Sub Total(Additions) 0.00 PA Owner Driver 320.00 GST @18.00% 1,587.00
Sub Total (Deductions) 28,508.00 LL to Paid Driver IMT 28 50.00 TOTAL PAYABLE PREMIUM 10,404.00
Total 5,031.00 Sub Total (Additions) 370.00 Stamp Duty Rs. 1
Sub Total (Deductions) 0 Receipt Date 27/08/2025
Total 3,786.00 Receipt Amount 10,404.00
Payment Mode Online
Paying Party SARDAR SINGH

CHEQUE DETAIL
Cheque Number Cheque Date Bank Name Branch Name Branch Code Cheque Signatory MICR No
PB127658124 27/08/2025 BankName SARDAR SINGH

Europ Assistance India Private Limited, Address: 7th, Floor, Building No. 2, Star Hub, Near ITC Maratha Hotel, Sahar, Andheri East, Mumbai Suburban, Maharashtra, Contact No.‐18002102051

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, 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 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: 27/08/2025 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. 32325721 DTD 28/12/2017 AND
CERT. NO. 780 DTD 28/12/2017 ISSUED BY
TREASURY OFFICER, GURGAON

IP Address: 10.82.6.140
Print Date: 27/08/2025
United India Insurance Company Ltd : IRDA Reg: No : 545 04:10:09 hours
Underwritten by Policy Bazaar on 27‐08‐2025 04:10:09hours
 MOTOR INSURANCE ‐ PRIVATE CAR PACKAGE POLICY SCHEDULE
Duly Constituted Attorneys
 MOTOR INSURANCE ‐ PRIVATE CAR PACKAGE POLICY SCHEDULE
* 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".