UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
MOTORCYCLE / SCOOTER - LIABILITY ONLY POLICY
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 0519003119P112875905 Certificate Number 0519003119P112875905
Customer Id 23031078392 Issuing Office Address Code 051900
6-6-4/1/7
Name of the Insured MR KOTA SRINIVASA RAO
NH 7 ROAD, BHUKTAPUR, ADILABAD, ADILABAD, ANDHARA PRADESH
S/O GANGAIAH, 5-117/A, BOATH
504001
ADILABABAD
Address of the Insured 504304
TELANGANA
ADILABABAD
TELANGANA Telephone (08732) 230924
Business/Occupation Others Telephone :
Insured's Declared Value 0

Period of Insurance From 00:00 Hrs of 28/01/2020 To Midnight of 27/01/2021

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)
AP - 01 - AE - HA10EJCHM80631 MBLHA10AMCHM40853 Hero Honda / SPLENDOR PLUS SOLO WITH
No 2012 100 2
9932 ALLOY PILLION
Registration Authority Geographical Area Financier
TS01 ADILABAD INDIA
Amount in words: One thousand two hundred eleven 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.
Limitations as to use Premium: 1,027.00
The policy covers use of the vehicle for any purpose other than CGST(9%): 92.00
a) Hire or Reward
SGST(9%): 92.00
b) Carriage Goods (other than samples or personal luggage)
c) Organized Racing Stamp Duty: 1.00
d) Pace Making Total(Rounded Off): 1,211.00
e) Speed Testing and Reliability Trials Receipt Number : 10105190019113770811
f) Use in connection with Motor Trade Receipt Date: 04/01/2020
DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: AGD0110656
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor GATLA BALARAMA KRISHNA , Mobile:
Vehicles Act 1988 9676219565
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:
Development Officer Code:
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. For and On behalf of
Date of Issue: 04/01/2020 United India Insurance Co. Ltd.
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
Duly Constituted Attorney
 MOTOR INSURANCE - MOTORCYCLE / SCOOTER - LIABILITY ONLY POLICY SCHEDULE
Policy Number :0519003119P112875905 Previous Policy No :0519003118P112856745
Geographical Area :India(A) Insurance Start Date & Time :28/01/2020 00:00 (hours)
Insured Name/ID : MR KOTA SRINIVASA RAO/23031078392 Insurance expiry Date & Time :27/01/2021 midnight
Insured address : Policy Issuing Office Address :
S/O GANGAIAH, 5-117/A, BOATH 6-6-4/1/7 NH 7 ROAD, BHUKTAPUR, ADILABAD, ADILABAD, ANDHARA PRADESH ,GST No.:-
City: ADILABABAD District: ADILABABAD 36AAACU5552C1ZK
State: TELANGANA Pincode: 504304 City: ADILABABAD District: ADILABABAD
Telephone: Mobile: 9985202744 State: TELANGANA Pincode: 504001
Telephone:(08732) 230924
Business Channel Code: AGD0110656 Business Channel Sub Code:
Dealer Name: Agent Name:GATLA BALARAMA KRISHNA
Dealer Code: Land Line No: ,Mobile:9676219565
VEHICLE DETAILS
Obsolete Vehicle & Engine Year Of
Registration Number AP - 01 - AE - 9932 No & HA10EJCHM80631 2012
Number Manufacture
RTA Name TS01 ADILABAD Chassis Number MBLHA10AMCHM40853 Cubic Capacity/KW 100
Hero Honda & SPLENDOR
Registration Date 31/01/2013 Vehicle Make & Model Type Of Body SOLO WITH PILLION
PLUS ALLOY
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
1500000 Compulsory 100 Imposed 0 Voluntary 0
(Under Section IV)
SCHEDULE OF PREMIUM ( )
A-OWN DAMAGE PREMIUM B-LIABILITY PREMIUM TOTAL PREMIUM
Premium(A+B) 1,027.00
B. Basic TP 752.00
CGST(9%) 92.00
Total 752.00 SGST(9%) 92.00
Gross OD(A) 0.00 TOTAL PAYABLE PREMIUM 1,211.00
Add :
Stamp Duty 1.00
Compulsory PA for Owner Driver 275.00 SAC Code 9971
3119I112875905 &
Invoice No & Date
04/01/2020
Sub Total (Additions) 275.00 Receipt Number 10105190019113770811
Receipt Date 04/01/2020
Receipt Amount 1,211.00
Gross TP(B) 1,027.00 PAYMENT GATEWAY FOR
Payment Mode
CD
Total Liability Premium 1,027.00
Paying Party MR KOTA SRINIVASA RAO

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.

Integrity - A way of Life. Please take pledge through the link https://pledge.cvc.nic.in.

Date & Signature of Proposal : 04/01/2020

In Witness Whereof this policy has been signed at DO ADILABAD 051900 on this 04th day of January ,2020

For United India Insurance Company Limited

Affix Policy Stamp

Duly Constituted Attorneys

IP Address: 10.90.240.24
Issuing Agent: GATLA BALARAMA KRISHNA Printed By : CUSTOMER @ 04/01/2020 3:56:17 PM Agent User Name: GATKRI00
Agent Location: 051900 Underwritten By - GATKRI00 ( DIRECT AGENT )

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