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540800311603000000809

This policy is subject to terms and conditions and IMT Endorsement Nos. pri nted herei n / attached hereto

SCHEDULE OF PREMIUM

UNITED INDIA INSURANCE COMPANY LIMITED

Add :
MICRO OFFICE,MO PHULWARISARIF, BALAMICHAK, ANISABAD, PHULWARISARIF,
PATNA BIHAR
PATNA - 800002 BIHAR
PH: (938) 6888853 FAX: EMAIL:

AMOUNT IN WORDS: Seven hundred twelve rupees only

MOTORCYCLE / SCOOTER
LIABILITY ONLY POLICY
TERMS AND CONDITIONS 540800311603000000809
As per the Indian Motor Tariff, Personal copy of the sam e is available f ree of cost on request. Further, the Indian Motor Tariff is also VEHICLE NO.:BR - 01 - CQ - 3495
av ailable and displayed at all United India Insurance company offices and on UIIC website : www.uiic.co.in
DISCLAI MER :
The Policy stands cancell ed or void in the event of Cheque Dishonor. the company may cancel the policy by sending 7 days notice in
case of any f raud or misrepresentation, non-disclosure of material fact or non-co-operation of the insured. PERIOD OF INSURANCE
FROM 00:00 Hrs of 07/03/2019
IMPORTANT NOT ICE
The Insured is not indemnified if the v ehicle is used or driven otherwise than in accordance with this Schedule. Any payment made by To Midnight of 06/03/2020
the Company by reason of wider terms appearing in the Certificate in order to comply with the Motor Vehicles 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.

Agency/Broker AGD0126503
Premium: 619.00 Receipt 1022109841602555364 Code:
Number: VIJAY KUMAR SINGH
Service Tax(Including Swachh Bharat Cess of 93.00 Receipt 07/03/2019 Direct Business:
0.5% And Kishi Kalyan Cess Of 0.5%): Date: Insured
Stamp Duty: 1.00 DebitNote
Number :
Developement
Officer Code:
MR MOHAMMAD IMTIYAZ
Total: 712.50 Document S/O MOHAMMAD KHALIL, LALAMIYA DARGAH, PHULWARI SHARIF
Cover Note No.:
Date : 801505
STax Regn
No :
AAACU5552CST001 Cover Note Date: PATNA
BIHAR
PHONE:
Anti Money Laundering Clause:-

operating offices as well as Company’s website.

Agent Name : VIJAY KUMAR SINGH
Date of Proposal and Declaration: 07/03/2019 Agent Code : AGD0126503
IN WITNESS WHEREOF, this policy has been signed at MO PHULWARISHARIF 210984 on this 07th day of March, 2019. Mobile/Landline : 8298996132
Number/Email

For and On behalf of

United India Insurance Co. Ltd

REGD. & HEAD OFFICE, 24, WHITES ROAD, CHENNAI - 600014

Website: http://www.ui ic.co.in, Emai l - info@uiic.co.in
Printed By : SAT36164 @ 07/03/2019 2:48:50 PM
Duly Constituted Attorney:
Underwritten by: SATISH KUMAR SAH (MO INCHARGE)

h t t p : / / 2 1 0 . 2 1 2 . 2 3 4 . 1 7 4 / C o n f i g u r a t o r / U n d e r w r i t i n g M a s t e r s / r e p o r t s / f r m P o l i c y S c h e d u l e . a s . . . 07/ 0 3/ 2 0 1 9 h t t p : / / 2 1 0 . 2 1 2 . 2 3 4 . 1 7 4 / C o n f i g u r a t o r / U n d e r w r i t i n g M a s t e r s / r e p o r t s / f r m P o l i c y S c h e d u l e . a s . . . 07/ 0 3/ 2 0 1 9
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Policy No. : 540800311603000000809

Policy No. : 540800311603000000809
X QRCode_LOGO
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UNITED INDIA INSURANCE COMPANY MOTORCYCLE / SCOOTER - LIABILITY ONLY POLICY

LIMITED SCHEDULE

CERTIFICATE OF INSURANCE Policy No. 540800311603000000809 Previous Policy No. 17080331156260007247

MOTORCYCLE / SCOOTER - LIABILITY ONLY POLICY
Customer Id 23025594283
(FORM 51 OF CENTRAL MOTOR VEHICLE RULES 1989)
Name MR MOHAMMAD IMTIYAZ
Policy No. 540800311603000000809 Certificate Number 540800311603000000809
Insured Details Tel (O): Tel (R): Fax
Customer Id 23025594283 Issuing Office Address Code 210984
MICRO OFFICE, MO PHULWARISARIF, BALAMICHAK, ANISABAD, Email: Mobile:
Name of Insured MR MOHAMMAD IMTIYAZ
PHULWARISARIF, PATNA BIHAR Business / Occupation None
Address of the S/O MOHAMMAD KHALIL, LALMIYA
Insured DARGAH, PHULWARI SHARIF Period of Insurance From 00:00 Hrs of 07/03/2019 To Midnight of 06/03/2020
Co-Insurance Type
801505 Particulars of Vehicle Insured
800002 Obsolete Seating
PATNA
PATNA Registration No. Obsolete Engine Chassis No.
BIHAR Make/Model Year of Mfg Type Of Body Cubic Capacity Including
BIHAR Vehicle No. Side Car
Telephone (938) 6888853
BR - 01 - CQ- No E3N6E ME1SE778 YAMAHA / RAY Z 2015 Metal 113 2
Busniess/Occupation None Telephone
3495 0070135 9F0042030
Effective date of commencement of Insurance for the pupose of Act from 00:00 Hrs on 07/03/2019

Date of Expiry of the Insurance Midnight on 06/03/2020 Registration Authority Auto Association Membership Geographical Area Extension
No.
Particulars of Vehicle Insured
Registration No. Obsolete Seating BR01 PATNA INDIA
Obsolete Engine Chassis No. Make/Model Year of Mfg Type Of Body Cubic Capacity Including Motor Vehicle in case of Motorised Two wheeler is deemed to include a side car attached to it.
Vehicle Trailer No.
Vehicle Side Car
BR-01-CQ- No E3N6E ME1SE778 YAMAHA /RAY Z 2015 Metal 113 2
Persons or classes of persons entitled to drive
0070135 9F0042030 Any person including Insured provided that a person holds an effective driving licence at the time of accident and is not disqualified
3495
from holding or obtaining such a licence. Provided also that the person holding an effective Learner’s Licence may also drive the
Registration Authority Geographical Area vehicle and such a person satisfies the requirement of Rule 3 of Central Motor Vehicle Rule, 1989.

BR01 PATNA INDIA

Amount in words: Seven hundred twelve rupees only Limitations as to use
Persons or classes of persons entitled to drive The policy covers use of the Vehicle for any purpose other than
Any person including Insured provided that a person holds an effective driving licence at the time of accident and is not disqualified a) Hire of Reward
from holding or obtaining such a licence. Provided also that the person holding an effective Learner’s Licence may also drive the b) Carriage Goods (other than samples or personal luggage)
vehicle and such a person satisfies the requirement of Rule 3 of Central Motor Vehicle Rule, 1989. c) Organized Racing
Limitations as to use Premium: 619.00 d) Pace Making
The policy covers use for: e) Speed Testing and Reliability trials
Service Tax(Including Swachh Bharat Cess of
a) Hire of Reward 0.5% And Kishi Kalyan Cess Of 0.5%): f) Use in connection with Motor Trade
93.00
b) Carriage Goods (other than samples or personal luggage)
c) Organized Racing Stamp Duty: 1.00
d) Pace Making Limits of liability As narrated in the Certificate of Insurance attached herewith.
Total (Rounded off): 712.00
e) Speed Testing and Reliability trials EXCLUSIONS :
f) Use in connection with Motor Trade Receipt Number : 1022109841602555326 1) Any accidental loss or damage or Liability / cause4d or sustained or incurred outside the geographical area.
Receipt Date: 07/03/2018 2) Any claim arising out of any contractual liability.
DebitNote Number: 3) Any accidental loss or damage to any property whatsoever or any loss or any expense whatsoever resulting or arising there from
or any consequential loss.
Document Date:
4) Any liability of whatsoever nature directly or indirectly caused by or constituted to or by or arising out of ionizing radiations or
STax Regn No.: AAACU5552CST001
contamination by radioactivity from any nuclear fuel. For the purpose of this exception, combustion shall include any self-sustaining
Limits of liability Agency/Broker Code: AGD0126503 process of nuclear fission.
Under Section II-I (i) Death or bodily injury in respect of any one VIJAY KUMAR SINGH 5) any accidental loss or damage or liability directly or indirectly caused by or contributed to, by or arising from nuclear weapons
accident: As per Motor Vehicles Act 1988 Direct Business: material.
Under Section II-I (ii) Damage to third party property in respect Developement Officer Code:
of any one claim or series of claims arising out of one event : 6) Any accidental loss, damage or liability directly or indirectly or proximately or remotely occasioned by contributed to, by or
6000 traceable to or arising out of or in connection with war, invasion, act of f oreign enemies, hostilities or warlike operations (whether
Cover Note No.: before or after declaration of war), civil war, mutiny, rebellion, military or usurped power, or by any direct or indirect consequence of
Cover Note Date: any of said occurrences or nay consequence thereof and in default of such proof, the Company shall not be liable to make any
Subjectt to IMT Endorsement No.s, terms and conditions printed herein / attached hereto 20 payment in respect of such a claim.
I/We hereby certify that the policy to which the ceertificate relates as well For and On behalf of
as the certificate of insurance are issued in accordance with provisions of United India Insurance Co. Ltd. Personal Accident covers for Owner-Driver CSI: 100000
Chapter X & XI of M.V Act, 1988. Underwritten by: SATISH KUMAR SAH (MO INCHARGE)

Duly Constituted Attorney:

Date of Issue: 07/03/2019
Underwritten by: SATISH KUMAR SAH (MO INCHARGE)

h t t p : / / 2 1 0 . 2 1 2 . 2 3 4 . 1 7 4 / C o n f i g u r a t o r / U n d e r w r i t i n g M a s t e r s / r e p o r t s / f r m P o l i c y S c h e d u l e . a s . . . 07/ 0 3/ 2 0 1 9 h t t p : / / 2 1 0 . 2 1 2 . 2 3 4 . 1 7 4 / C o n f i g u r a t o r / U n d e r w r i t i n g M a s t e r s / r e p o r t s / f r m P o l i c y S c h e d u l e . a s . . . 07/ 0 3/ 2 0 1 9