MOTOR INSURANCE PROPOSAL FORM

Development Officer's Name & Code: ARUN RAMDAS Broker's / Agent's Name & Code: PRASHANT MACHINDRA SHELKE /

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HIWALE / BD47459 AGD0108931

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Transaction ID: GC202303310076298295

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. .. .
Proposer's Name PRASAD BAJIRAO MATE PAN Number : BVMPM0972P
.. . District : .AHMADNAGAR
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Address for Correspondence City :
. . . Pincode: .423109
State : MAHARASHTRA

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Telephone, Fax Number & Mobile Phone No: Mobile No: 9527202121 E-mail Address:[email protected]

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Gender Male
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Type of Policy Required
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Period of Insurance From 04/04/2023 0:00 To 03/04/2024 midnight
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Details of Vehicle

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Reg. No. Engine And Year of Make Make & Model / Seating CC/Gross Color
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Chassis Number Type of Body Capacity Vehicle Weight
. . . . . . .

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MH-17-CT/2121
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M853M3066356 / MET00004A2A014765
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2022
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VESPA / SCOOTER
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2
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125
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AZZURO PROVENZA
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Registering Authority - Name and location :MH17 SHRIRAMPUR, AHMEDNAGAR DISTRICT
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HISTORY OF VEHICLE:
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Previous Policy Previous Year Date of Policy Date of First
. . . .
Number NCB Expiry Purchase &
. . . .
Regn.
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2024-04-03 00:00:00.0 2022-05-22 00:00:00.0

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DRIVER DETAILS :
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. . . . .
Driving License Driving License License Issuing Name of Relationship
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Number Expiry Date Authority Nominee With Nominee
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. . . . .

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USAGE OF VEHICLE:
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Voluntary Excess : Do you wish to Opt for Voluntary Excess over
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and above the Compulsory Policy Excess
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Are you a member of Automobile Association of India
no

. .
No
Is the vehicle fitted with the any Anti-Theft Device
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approved by ARAI
. .
yes
Whether the vehicle is driven by non-conventional source
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 MOTOR INSURANCE PROPOSAL FORM

Development Officer's Name & Code: ARUN RAMDAS Broker's / Agent's Name & Code: PRASHANT MACHINDRA SHELKE /

.
HIWALE / BD47459 AGD0108931

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Transaction ID: GC202303310076298295

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LPG-0.00,CNG-0.00,Fibre Glass Tank-0.00
Whether the vehicle is driven by Bi--fuel kit / Fibre Glass
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Tank Fitted
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Do you wish to restrict TPPD cover to Statutory limit of

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Rs.6000 / -only
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ADD-ON COVERS REQUIRED (In Rupees)
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No
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Theft of Accessories (Two Wheelers Only)
. .,
Legal Liabilities Applied

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PA Cover for Owner Driver

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0 / 0 person(s)
PA Cover for Named Persons
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PA cover for unnamed persons / Pillion / unnamed passengers 0 / 0 person(s)
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No
Courtesy Car
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No
Medical Expenses

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No
Nil Depreciation
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No
Engine and Gearbox Protection Standard Add On Cover
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Personal Effects
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Other Details
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Whether use of vehicle is limited to own premises
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No
Whether the vehicle belongs to foreign embassy
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No
Whether the vehicle is designed for use of blind / handicapped
persons
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No
Whether the vehicle is used for Driving Tuitions
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NA
Whether extension of Geographical Area is required
. .
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Do you wish to have a one page policy ?* Yes

* Note :Policy terms and conditions are as per India Motor Tariff and are displayed at www.uiic.co.in
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DECLARATION BY THE INSURED

I/we hereby declare that the statements made by me / us in this Proposal Form are true to the best of my/our knowledge and
belief and I/We hereby agree that this declaration shall form the basis of the contract between me/us and the United India
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Insurance Company Ltd.

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I/we also declare that if any additions or alterations are carried out after the submission of this proposal form then the same
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would be conveyed to the insurers immediately.

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Place Signature of the Proposer
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Date
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* This is a system generated document and any manual alteration / correction / overwriting in the document will make it invalid.
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