10/19/2019 FormOfCoverNote_Motor.

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Form Of Cover Note

KARNAL BRANCH OFFICEMotor Vehicle Insurance

IMD Name : PARAS RELAN IMD Code: 200227588625
Sub IMD Name : NA Sub IMD Code : NA
Policy Type : Package Liability Others(Specify) ____________________________Cover Note Number : USGIA/ 2019070808
Vehicle Type : Two Wheeler Private Car Good Carrier Passenger Carrier Miscellaneous
The Insured described in Form "52" referred to below, having proposed for insurance in respect of the Motor Vehicle(s) described therein and having paid the sum of Rs. 34035.00 as
stated below as premium, the risk is hereby held covered under the terms of the Company's usual form of applicable thereto(subject to any Special Conditions
mentioned below)unless the cover be terminated by the Company by notice in writing in which case the insurance will thereupon cease and a proportionate part of the premium otherwise
payable for such insurance shall be charged for the time the Company had been at risk.

Vehicle Year of Seating Cubic Gross Vehicle Weight

Body Type
(Make & Model) Manufacture Capacity Capacity (Goods Carrier)(Kgs)

SWARAJ MAZDA & SUPER ZT 54 2016 3 3455 OPEN 10250

Insured's Declared Value(IDV)(Rs.) for Vehicle and Accessories (Acc. not included in Manufacturer's listed selling price) Licensed Carrying Capacity
(Passenger Carrier)
Vehicle Side Car Electrical Acc. CNG/LPG Non-Electrical Acc.
900000 0 NA NA NA NA
Registration Number Place Of Registration Chassis Number Engine Number PUC Number PUC Center
HR 46 E 2699 ROHTAK 23023 16695
Chassis Number
Registration Number (For Trailer) Trailer Type (Agriculture/Forestry) Number of Trailers Trailer IDV (Rs.)
(For Trailer)
NA NA NA NA NA
Depreciation Waiver NA Daily Cash Allowance NA Key Replacement
Return to Invoice Accidental Hosp. Road Side Assistance
Add on Covers
Driving Train Protect Hydrostic lock cover Cost of consumables Secure Towing
Road Side Assistance Freedom Engine Protector NCB Protector
Additional risk, if any: Premium Details Amount(Rs.)
Financier's Name: ICICI BANK LTD. Basic Own Damage(OD) Premium 15534.00
Financier's Address: ROHTAK Add: IMT23 2330.00
State if the vehicle is under: Hire Purchase Lease Agreement Hypothecation Total Basic Own Damage 17864.00
Form "52"(India), Rule 142(I) of Motor Vehicle Rules, 1989 Less: De Tariff Discount 13398.00
Insured's Name: ASHOK KUMAR Basic OD after Discount 4466.00
Address Line 1: VPO.BHAGWANPUR Less: No claim Bonus(35%) 1563.00
Address Line 2: DISTT.ROHTAK Sum: Total OD(A) 2903.00
Liability Premium 26935.00
City/ District: ROHTAK Mobile Number 9896062950
Legal Liability to
Area/ Village: ROHTAK Phone Number - Add: 100.00
Cleaner/Conductor/Coolies
State: HARYANA Email Address NA
Add: PA-Owner Driver 225.00
Pin Code: 124001 GST Number NA
Add: LL-Paid Driver 50.00
Nominee Name:
Sum: Total Cover Liability(C) 375.00
Relationship With Proposer: Sum: Total Liability(B) 27310.00
Policy Duration: 1 Year
From: 20/10/2019 Time: 00:01 AM Premium(A+C) 3278.00 Basic TP 26935.00
Period of
Insurance: IGST(18%) 0.00 IGST(12%) 0.00
To Midnight of: 19/10/2020
CGST(9%) 295.02 CGST(6%) 1616.10
Payment Mode Instrument Date of Name of Bank drawn
Amount(Rs.) SGST(9%) 295.02 SGST(6%) 1616.10
(DD/ Cheque/ EFT, Others) Number Issuance on
ELECTRONIC FUND TRANSFER 50540214 19/10/2019 CORPORATION BANK 34035.00 TOTAL OD(E) 3868.04 TOTAL TP(F) 30167.20
SpecialCondition: Premium Payable (E + F) 34035.00
NA

Warranty:
Warranted that the Assured named herein/owner of the vehicle insured holds a valid Pollution Under Control (PUC) Certificate on the date of
commencement of the Policy and renews and maintains valid and effective PUC Certificate during the duration of the Policy period. If the PUC is
not found valid on the date of loss, the company shall repudiate the OD claim made under the Policy.

Driver Clause:
Any Person including Insured: Provided that a person driving holds an effective driving licence at the time of the 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 when not used for the transport of passengers/goods at the time of the accident and that such a
person satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules,1989
Limitations As To Use(Package Policy)
1.Goods Carrying Vehicles/Miscellaneous&Special type of Vehicles/Passenger Carrying Vehicles:
The Policy covers use only under a permit within the meaning of Motor Vehicles Act,1988 or such a carriage falling under Sub-
section(3)of Section 66 of Motor Vehicles Act,1988. The Policy does not cover use for;a)Organised racing,b)Pace
making,c)Reliability trials,d)Speed testing,e)Use whilst drawing a trailer except the towing(other than for reward)of any one
disabled Mechanically propelled vehicle.
2.Private Cars/Two Wheelers:
The Policy Covers use of the vehicle for any purpose other than: a)Hire or reward, b)Carriage of goods(other than samples or
personal luggage),c)Organized racing,d)Pace making,e)Speed testing,f)Reliability trials,g)Any purpose in connection with
Motor Trade.

Prohibition of rebates-Section 41 of The Insurance Act,1938

1. No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind or risk relating
to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or
continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer.
2. Any default in complying with the provisions of this Section shall be punishable with fine which may extend to Rs.500/-.

GSTIN : 06AAACU8917F1ZA

https://www.usgi.co.in/usgi/Application/Cover Note/MotorCoveNoteForm.aspx?CvrNo=2019070808&Poltype=Package&Category=MO 1/2

10/19/2019 FormOfCoverNote_Motor.aspx
USGI IRDAI REGISTRATION NO: 134
SAC CODE : 997134
Subject to IMT Endorsement Nos. & Memorandum printed herein / attached hereto: 7,15,17,21,23,25,28,40
Note:
The cover note is valid for 60 days from the date of issue.
In the event of dishonor of premium cheque(s), insurance cover provided under this document shall be void abinitio.
I the Registered owner of the vehicle confirm that the above particulars in respect of my vehicle, No Claim Bonus eligibility are accurate and true to the best of my knowledge. I understand that any
incorrect information furnished by me may deprive me of any benefits under the said insurance.
____________________________________
Signature of the Insured
I/We hereby certify that this Cover Note is issued in accordance with the provisions of Chapter XI of the Motor Vehicle Act, 1988
For Universal Sompo General Insurance Company Limited
Place of Issue: KARNAL
Date of Issue: 19/10/2019 US 2692
Time of Issue: 5:15 PM Authorised Signatory
Toll Free Numbers: 1-800-22-4030 (for MTNL/BSNL users) or 1-800-200-4030 (other users) Landline Numbers: +91-22-27639800 / +91-22-39133700
E-mail Address: [email protected]. Fax Number: 022-39171419
Insurance is a subject matter of solicitation

https://www.usgi.co.in/usgi/Application/Cover Note/MotorCoveNoteForm.aspx?CvrNo=2019070808&Poltype=Package&Category=MO 2/2