Office Copy

UNITED INDIA INSURANCE COMPANY LIMITED

MUMBAI - 400021 MAHARASHTRA
PH: (022) 22822394,(022) 49799210 FAX: EMAIL:

GROUP PERSONAL ACCIDENT TAILOR MADE POLICY

POLICY NO.: 0205004224P101593076

PERIOD OF INSURANCE
From 00:00 Hrs of 01/05/2024
To Midnight of 30/04/2025

Insured
LIFE INSURANCE CORPORATION OF INDIA
3RD FLOOR, EAST WING, MUMBAI DIVISIONAL OFFICE-IV, YOGAKSHEMA, JEEVAN BIMA MARG,

400021
MUMBAI
MAHARASHTRA

Agent Name :
Agent Code :
Mobile/Landline Number/Email :

The genuineness of the policy can be verified through "Verify Your Policy" link at www.uiic.co.in.

For any Information, Service Requests, Claim intimation and Grievances please write to 020500@uiic.co.in

Download Customer App(www.uiic.co.in). REGD. & HEAD OFFICE, 24, WHITES ROAD, CHENNAI - 600014.
Website: http://www.uiic.co.in
Printed By : CUSTOMER @ 09/05/2024 9:13:06 PM

This document is digitally signed

Signer: KALAIVENI SUBBIAH

Date: Thu, May 9, 2024 21:11:30 IST
Location: United India Insurance Company Ltd
1/6 Reason: Signing Policy for UIIC
Office Copy

GROUP PERSONAL ACCIDENT TAILOR MADE POLICY

SCHEDULE

Policy No.: 0205004224P101593076 Prev.Pol.No.: 0205004223P101198330

Name of Customer/ID LIFE INSURANCE CORPORATION OF INDIA/1152460768
Tel.(O): 66598348 Fax: Tel.(R): Mobile: 7008854851
Business/Occupation : None Email:
Period of Insurance: From 00:00 Hours of 01/05/2024 To MIDNIGHT of 30/04/2025

Coinsurance:-

Company Name Office Code Leader(L)/Non-Leader(N) Share(%)

UIIC 020500 L 90
TNIA 120300 N 10

Premium : Sixty-five lakhs fifty-nine thousand three hundred twenty-five rupees only

Unique Reference Code: UII020500PA0123189502425

Risk Category No. of Person/Category Covers Premium Loading/Discount Caculated Amount

RiskCategory II 1203855 Table III Death PTD PPD 240,771,000.00

Total Sum Insured for the

Total No Of Person 1203855 240771000000
Group

Special Conditions:-
Unnamed GPA Insurance to 1203855 Active Agents as on 31-03-2024 of 112 Divisional Offices across India of
LIC of India for Table III Cover -Death+Permanent Total Disability+ Permanent Partial Disability due to
accident. Per Person Capital Sum Insured Rs. 2 lakh. Covid-19, Pandemic and other Communicable diseases
are excluded. A claim is admissible due to accident, if the total number of persons on roll should not exceed
with the number of person prescribed in the policy schedule.

Net Premium: 6,559,325.00

CGST(9%): 590,339.00
SGST(9%): 590,339.00
Stamp Duty: 10.00
Total : 7,740,003.00
Receipt Number : 10102050024101598470
Receipt Date: 30/04/2024
Agency/Broker Code :
Dev. Officer Code :
Direct Business :

Customer GST/UIN No.: 27AAACL0582H4ZJ Office GST No.: 27AAACU5552C1ZJ

SAC Code: 997133 Invoice No. & Date: 4224I101593076 & 30/04/2024
Amount Subject to Reverse Charges-NIL

We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the
aggregate turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said
sub-rule.
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 of Proposal and Declaration: 01/05/2024

IN WITNESS WHEREOF,the undersigned being duly authorised has hereunto set his/her hand at DO 5 MUMBAI 020500 on this 30th day of
April 2024 .

For and On behalf of

United India Insurance Co. Ltd.

Affix Policy
Stamp here.

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Duly Constituted Attorney(s)
Underwritten By - BHO34107 ( DO UW CUM CASHIER ) , Approved By -
ANI60129(COINSURER HUB APPROVER),APU23640(RO UNDERWRITER
NEW)

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 Annexure to the Agreement
Annexure - A
Generic Co-Insurance Underwriting Slip

Unique Reference code: UII020500PA0123189502425

Insurer: UNITED INDIA INSURANCE CO. LTD.

Policy Issuing Office Details: ROHIT CHAMBERS, 5TH FLOOR, JANMABHOOMI MARG, FORT
MUMBAI-400001 MAHARASHTRA
Contact No:-(022) 22822394,(022) 49799210

Insured: LIFE INSURANCE CORPORATION OF INDIA ( 1152460768 )

Period of Insurance: 01/05/2024 To 30/04/2025

Class of Insurance : Personal Accident

Type of Policy Issued: Group Personal Accident Tailormade Policy

Subject matter of Insurance: Group Personal Accident Tailormade Policy

Total Sum Insured: 240,771,000,000.00

Break up under various section of policy if applicable:

Probable Maximum Loss:

Deductibles (on each & every claim):

Limit of Liability:

Premium: 6,559,325.00

Total Premium: 7,740,003.00

Terms and Conditions of cover:

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Exclusions:

Loss Experience:

Claims History:

Other Relevant information:

Rate: __________%

Cash call Limit:

Terms of administration of business as per co-insurance agreement dated-

Co-Insurance clause: As Attached

Lead Insurer (Name & Share): UIIC - 90%

Co-insurers (Name & Share):

Sr. As Leader/Co- Broker Brokerage

Insuring Party * Share %
No. Insurer Name Share
1 UNITED INDIA INSURANCE CO.LTD. Leader 90 NA 0.00
2 THE NEW INDIA ASSURANCE CO. LTD. Follower 10 NA 0.00

*Name of Insurer

Intermediary Fees (Brokerage):

Authorized Signatory:

Full address of Policy issuing office and telephone no. for contact: ROHIT CHAMBERS, 5TH FLOOR, JANMABHOOMI MARG, FORT
MUMBAI-400001 MAHARASHTRA
Contact No:-(022) 22822394,(022) 49799210

Date:

5/6
Annexure - A-3

In addition to Generic Co-Insurance Underwriting Slip following is required for PA Cover

Unique Reference code UII020500PA0123189502425

Policy No 0205004224P101593076

Insured Persons 1203855

Schedule of Persons Covered

Highest Single Capital Sum-Insured 240,771,000,000.00

Unnamed GPA Insurance to 1203855 Active Agents as on 31-03-

2024 of 112 Divisional Offices across India of LIC of India for Table
III Cover -Death+Permanent Total Disability+ Permanent Partial
Disability due to accident. Per Person Capital Sum Insured Rs. 2
Special Conditions
lakh. Covid-19, Pandemic and other Communicable diseases are
excluded. A claim is admissible due to accident, if the total number
of persons on roll should not exceed with the number of person
prescribed in the policy schedule.

Additions & Deletions

Claim Experience for 5 Years

These are suggestive and not exhaustive; Lead Insurer may add Clauses as necessary.

This is a system generated document and any manual alteration / correction / overwriting in the document will make it invalid.

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