UNITED INDIA INSURANCE COMPANY LIMITED

CERTIFICATE OF INSURANCE
MOTORCYCLE / SCOOTER - PACKAGE
UIN: IRDAN545RP0222V01200708
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Policy No. 0729033121P105983756 Certificate Number 0729033121P105983756
Customer Id Issuing Office Address Code 072903
23090456153
BRANCH OFFICE, 2ND FLOOR . SANTHOM TOWERS
Name of the Insured MR B. SHEIKHUNHI
OPP : BUS STAND BELTHANGADY
S/O B. CHERIYAMONU, RETIRED. ADMINISTRATIVE
574214
OFFICER,UNITED INDIA INSURANCE CO.,LTD, BELTHANGADY DK
KANARA - SOUTH (MANGALORE)
Address of the Insured KARNATAKA
574214
Telephone (08256) 232566
KANARA - SOUTH (MANGALORE)
KARNATAKA
Business/Occupation None Telephone :
Insured's Declared Value 20000

Period of Insurance From 00:00 Hrs of 26/09/2021 To Midnight of 25/09/2022

Particulars of Vehicle Insured
Registration No.
Trailer Obsolete Vehicle Cubic Seating including
Engine No. Chassis No. Make/Model Type of Body Year of Mfg
Vehicle (if Capacity/KW driver
any)
KA - 21 - L - JC44E5037389 ME4JC448JB7037410 HONDA MOTORCYCLE & SCOOTER Solo with Pillion
No 2011 110 2
6850 INDIA PVT LTD / ACTIVA i
Registration Authority Geographical Area Financier
KA21 PUTTUR INDIA
Amount in words: One thousand two hundred seventy-four 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: 1,080.00
The policy covers use of the vehicle for any purpose other than CGST(9%): 97.00
a) Hire or Reward
SGST(9%): 97.00
b) Carriage Goods (other than samples or personal luggage)
c) Organized Racing Stamp Duty: 1.00
d) Pace Making Total(Rounded Off): 1,274.00
e) Speed Testing and Reliability Trials Receipt Number : 10107290321106418561
f) Use in connection with Motor Trade Receipt Date: 18/09/2021
DebitNote Number:
Document Date:
Limits of Liability Agency/Broker Code: AGD0113913
Under Section II-I (i) Death or bodily injury in respect of any one accident; As per Motor SHAROON AHAMED . , Mobile:
Vehicles Act 1988 9739609158
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 22
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: 18/09/2021 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

This document is digitally signed

Signer: N MOHAN SANKAR

Date: Sat, Sep 18, 2021 21:33:06 IST
Location: United India Insurance Company Ltd
1/2 Reason: Signing Policy for UIIC
 MOTOR INSURANCE - MOTORCYCLE / SCOOTER - PACKAGE(UIN: IRDAN545RP0222V01200708) POLICY SCHEDULE
Policy Number :0729033121P105983756 Previous Policy No :0729033120P106726909
Geographical Area :India(A) Insurance Start Date & Time :26/09/2021 00:00 (hours)
Insured Name/ID : MR B. SHEIKHUNHI/23090456153 Insurance expiry Date & Time :25/09/2022 midnight
Insured address : Policy Issuing Office Address :
S/O B. CHERIYAMONU, RETIRED. ADMINISTRATIVE OFFICER,UNITED INDIA BRANCH OFFICE, 2ND FLOOR . SANTHOM TOWERS OPP : BUS STAND BELTHANGADY ,GST No.:-
INSURANCE CO.,LTD, BELTHANGADY DK 29AAACU5552C1ZF
KANARA - SOUTH KANARA - SOUTH City: KANARA - SOUTH (MANGALORE) District: KANARA - SOUTH (MANGALORE)
City: District:
(MANGALORE) (MANGALORE) State: KARNATAKA Pincode: 574214
State: KARNATAKA Pincode: 574214 Telephone:(08256) 232566
Telephone: Mobile: 9448348786
Business Channel Code: AGD0113913 Business Channel Sub Code:
Dealer Name: Agent Name:SHAROON AHAMED .
Dealer Code: Land Line No: ,Mobile:9739609158
VEHICLE DETAILS
Obsolete Vehicle & Engine Year Of
Registration Number KA - 21 - L - 6850 No & JC44E5037389 2011
Number Manufacture
RTA Name KA21 PUTTUR Chassis Number ME4JC448JB7037410 Cubic Capacity/KW 110
HONDA MOTORCYCLE &
Registration Date 19/10/2011 Vehicle Make & Model SCOOTER INDIA PVT LTD Type Of Body Solo with Pillion
& ACTIVA i
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
20000 0 0 0 0 0 20000 100%
OTHER DETAILS
Unique
Financier Policy Subject to IMT Endorsements Applicable Addon-covers/Services
Reference Code
22
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) 1,080.00
Basic premium on Vehicle and Accessories B. Basic TP 752.00
CGST(9%) 97.00
A. Basic OD 105.60 Total 752.00 SGST(9%) 97.00
Total 105.60 TOTAL PAYABLE PREMIUM 1,274.00
Add :
Stamp Duty 1.00
Compulsory PA for Owner Driver 275.00 SAC Code 997134
3121I105983756 &
Less : Invoice No & Date
18/09/2021
No Claim Bonus 50% 52.80 Sub Total (Additions) 275.00 Receipt Number 10107290321106418561
Receipt Date 18/09/2021
Sub Total (Deductions) 52.80 Receipt Amount 1,274.00
Gross TP(B) 1,027.00 Payment Mode
Gross OD & TP: Paying Party MR B. SHEIKHUNHI
Gross OD(A) 53.00 1,080.00
(A) + (B)

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 : 18/09/2021

In Witness Whereof this policy has been signed at BO BELTHANGADY 072903 on this 18th day of September,2021

For United India Insurance Company Limited

Affix Policy Stamp

Duly Constituted Attorneys

IP Address: 106.193.51.110
Issuing Agent: SHAROON AHAMED . Printed By : SHAAHA00 @ 18/09/2021 9:33:01 PM Agent User Name: SHAAHA00
Agent Location: 072903 Underwritten By - SHAAHA00 ( DIRECT AGENT )

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