Office Copy

UNITED INDIA INSURANCE COMPANY LIMITED

NO 29,NORTH CAR STREET,TIRUCHENDUR
MO TIRUCHENDUR - 628215 TAMIL NADU
PH: (4639) 246650,(4639) 242095 FAX: EMAIL:

INDIVIDUAL PERSONAL ACCIDENT POLICY

POLICY NO.: 0901814220P111699098

PERIOD OF INSURANCE
From 00:00 Hrs of 13/01/2021
To Midnight of 12/01/2022

Insured
MR MARISELVAM KRISHNAN
S/O KRISHNAN 4/59 THERKKU THERU THERKU KADAYAM TIRUNELVELI

627415
TIRUNELVELI
TAMIL NADU

IMPORTANT NOTICE: KINDLY UPDATE YOUR AADHAAR NO. AND PAN/FORM 60. PLEASE IGNORE IF ALREADY UPDATED.

Agent Name :
Agent Code :
Mobile/Landline Number/Email :

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 090181@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 @ 12/01/2021 5:14:34 PM
Office Copy

INDIVIDUAL PERSONAL ACCIDENT POLICY

SCHEDULE
Policy No: 0901814220P111699098 Previous Policy Number
Customer name/ID
MR MARISELVAM KRISHNAN /23098840927
:
(4639) 246650,
Tel.(O) Fax Tel.(R) Mobile
(4639) 242095
Bussiness/Occupation None E-Mail
Period Of Insurance From 00:00Hrs of 13/01/2021 To MidNight Of 12/01/2022

Premium: Five hundred forty rupees only

Coinsurance UIIC 090181 : 100%

Name of the insured Age Occupation Relationship Risk Category CB% CB(in amount)
MARISELVAM KRISHNAN 26 Others Self RiskCategory III 0 0

Name Covers CSI( ) Premium Risk Loading/Discount Premium

MARISELVAM KRISHNAN Table I Death 600,000.00 540.00

Net Premium (After Loading and Discount) : 540.00

Assignee Details
Name Of Assignee Relationship

Net Premium: 540.00

CGST(9%): 49.00
SGST(9%): 49.00
Stamp Duty: 30.00
Total : 638.00
Receipt Number : 10109018120112824227
Receipt Date: 12/01/2021
Agency/Broker Code :
Dev. Officer Code :
Direct Business : Walk-In
Office Copy

Customer GST/UIN No.: Office GST No.: 33AAACU5552C1ZQ

SAC Code: 9971 Invoice No. & Date: 4220I111699098 & 12/01/2021
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: 13/01/2021

IN WITNESS WHEREOF,the undersigned being duly authorised has hereunto set his/her hand at MO TIRUCHENDUR 090181 on this 12th
day of January 2021 .

For and On behalf of Consolidated

United India Insurance Co. Ltd. additional Stamp
Duty Paid as per
Tamilnadu
Government G. O. RT
no.222 dated
10/07/2020 for the
period from
01/04/2020 to
Duly Constituted Attorney(s) 31/03/2021
Underwritten By - NAN45338 ( MO INCHARGE )

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