(trr<arcn 6T s{6q) {A GOVT, OF INDIA UNDERTAKNG}

rft{a cs sula Hsidq : ffi'rm Eftr"(, A'25 /2t , enrs fift fu, Ti ftd Hegd, & Head 0ffice : 0riental House, A'25/27, Asal Ali Road, New Delhi- 110 002

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Mator Vehicle lnsurance Gover
NoteNo.cI{D-C 783999
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Time
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A.M./P.M.
Date of lssue
The insured described in Form "52" referred to below, having
th6 MotorVehjcle (s) describedtherein and having paid the sum ot Rs

risk is hereby held coverod under the terms of the

mentionsd below) unless the cover be tsrminated by the

cas€ th6 insutanco will thareupon ceaso and a
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payable for such insuranc€ shall be chargsd forthe time
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Licensed Carrying
i\,{ake Name of Bank/
ct the Vehicle
Capacity (LCC)
' (Passenger +,Hf Financing lnstitution
Carrying Vehicle)

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Additional risks, if anY SPecial conditions
*i{ SZ Form 52
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Registration number and description of the vehicle insured-
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Date cf expiry of insurance
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Persons or classes of persons entitled to drive
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Any Limitations as to use of motor vehicle
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The period of validity of this cover note will expire on er J I I F/ t s' v I v

Particulars '
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ll*nie herebi: certify that thii note is issued in accordance with provisions of chapter xl of the Motor Vehicle Act, 988'
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