New Business_620550651563_TRACKON_125218

To Date: 04-May-2025
URC CONSTRUCTION PVT LTD

NCRTC PROJECT- LOT-P11 L2

NATIONAL CAPITAL REGION TRANSPORT,
CORPORATION,A-97
SECTOR-2, PANCHWATI ROAD, SHATABDI
NAGAR
MEERUT-250103
MEERUT
UTTAR PRADESH
INDIA
09AAACU2425Q1ZY
Policy No: 2250035566
Client Id : 6205582099
We thank you for choosing Tata AIG General Insurance Company Ltd. as your preferred insurer. Your Policy No. is 2250035566 We are glad that
you have chosen our product Employees Compensation Insurance and given us an opportunity to structure an insurance cover that suits your
needs. We cater to most of the Micro, Small and Medium Enterprises . As one of the largest and most established insurance companies, we care
for you and understand your unique needs of coverage and would always strive to offer convenience and range of products that cater
continuously to your ever increasing and evolving needs.

We have provided insurance based on the information furnished by you and by accepting this policy, you agree that the information furnished to
us is true, accurate and complete. We are enclosing your policy document along with transcript of information furnished to us for providing
insurance. You are requested to go through the document carefully and let us know if any error/discrepancy within 15 days of receipt of the
policy to enable us to make necessary changes otherwise all particulars will be deemed correct

Also enclosed for your convenience are forms to help you reach us for any 'changes to your policy’ and the 'Claim intimation process and
documents'. Please keep these handy in the event of a claim under the policy.
You may call our Toll Free Customer Service Helpline 1800 266 7780 and enjoy a hassle-free service and claims settlement
experience.
We look forward to a long and mutually beneficial relationship and providing you wider range of benefits in the years to come.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding a sale.
Tata AIG General Insurance Company Limited.
Regd Office: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013, Maharashtra, India.
Toll Free No. (24x7): 1800 266 7780 l Email: customersupport@[Link]
IRDA of India Registration No: 108 | Website: [Link] | CIN: U85110MH2000PLC128425 | PAN: AABCT3518Q | UIN: IRDAN108CP0011V02202122
 EMPLOYEES COMPENSATION INSURANCE
POLICY SCHEDULE
(Forming part of Policy no.2250035566 whose terms are attached herewith)

1. Intermediary name: MANGAYARKARASI

2. Intermediary License Number: AGINEFKPM5527K
3. Intermediary Code: 1756710000
4. Intermediary Contact No: 9566306969
5. Policy Issuing Office: CHENNAI
6. Insured Name: URC CONSTRUCTION PVT LTD
[Link] Address: NCRTC PROJECT- LOT-P11 L2
NATIONAL CAPITAL REGION TRANSPORT, CORPORATION,A-97
SECTOR-2, PANCHWATI ROAD, SHATABDI NAGAR
MEERUT-250103
MEERUT
UTTAR PRADESH
INDIA
Place of Supply : UTTAR PRADESH
State Code : 09

8. Nature Of Business

CIVIL

9. GSTIN of the Insured:09AAACU2425Q1ZY

10. Laws: The Policy covers Liability of the Insured under the following Law(s) shown as covered, subject to claim being otherwise admissible
as per terms, conditions and exclusions of the Policy and subject to Limit of Indemnity as stipulated against each Law:

LAW LIMIT OF INDEMNITY COVERAGE

10(a) Employee’s Compensation Act,1923and Subject otherwise, to the terms, conditions & Yes
subsequent amendments thereof prior Exclusions of the Policy, the amount of liability
to the date of issue of this Policy incurred by the Insured.

Fatal Accident Act, 1855 and Subject otherwise, to the terms, conditions &
10(b) Yes
subsequent amendments thereof prior Exclusions of the Policy, the amount of liability
to the date of issue of this Policy incurred by the Insured.

10(c) Common Law Subject otherwise, to the terms, conditions & Yes
Exclusions of the Policy, the amount of liability
incurred by the Insured, but not exceeding:-

a) Limit Per Employee for any number ofaccidents

during Period of Insurance
Rs. Not applicable

b)Limit Per Accident for any number of Employees

Rs. Not applicable

c)Aggregate Limit for all accidents and claims

arising therefrom during the Period of Insurance
Rs. 750000000

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding a sale.
Tata AIG General Insurance Company Limited.
Regd Office: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013, Maharashtra, India.
Toll Free No. (24x7): 1800 266 7780 l Email: customersupport@[Link]
IRDA of India Registration No: 108 | Website: [Link] | CIN: U85110MH2000PLC128425 | PAN: AABCT3518Q | UIN: IRDAN108CP0011V02202122
11. Period of Insurance:
From 00:00 Hrs of 04/04/2025 to midnight of 03/07/2025 (both days inclusive)
12. Premium Details:

Net Premium (Rs): 10,346

IGST @ 18% 1,862
Stamp Duty 5.2
Total Premium 12,213

Rupees Twelve Thousand Two Hundred Thirteen And Twenty Paise

Gross Premium (In Words):
And Paise Zero Only

13. Details of Employees Covered:

Refer Annexure “W”

[Link] to following clauses:

Special conditions:

1 Medex aggregate expenses upto INR 5000000 for the policy period
2 Subject additionally to the following conditions, limitations, warranties.
3 Medical expenses on actual basis
4 Warranted that workers involved in underground work such as mines, tunneling, etc. and/or blasting are not covered.

Warranted that employees working above 9 meters should be properly harnessed and use adequate safety measures including Safety
5
Helmets
6 Notional extension as per EC Act

Risk Location Address: National Capital Region Transport Corporation, Package M9 - Fabrication, Supply, Erection and Fixing of Electric
7 boom in 15 elevated stations from Sarai kale khan to New Ashok Nagar and from Murad Nagar to Modipuram Depot of Delhi Meerut RRTS
corridor, Meerut - 250103.
8 Jurisdiction - India
9 Including cover for Contractor and sub contractor workers
10 Warranted that the medical expense coverage under the policy will be valid for a period not exceeding 2 years from the date of accident
11 Loss History for last 3 years: - no

Subject to terms and Conditions of Employees Compensation insurance Policy wordings attached herewith.

Stamp Duty of Rs.5.2/ - is paid as provided under Article 47(CC) of Indian Stamp Act, 1899 and included in Consolidated Stamp Duty Paid to the
Government of Maharashtra Treasury vide Order of Addl. Controller Of Stamps, Mumbai at General Stamp Office, Fort, Mumbai - 400001., vide this
Order No. LOA/ENF1/CSD/90/2024/25/5 Validity Period Dt.16/01/2025 To Dt.31/12/2027/5 Date:01/01/2025

Date: 04/04/2025

This Policy and its conditions should be examined, and if incorrect returned at once for alteration. Every change affecting the risks insured by
this Policy must be immediately advised to the Company. Failure to do this might result in the insurance ceasing to be of effect. The Policy is not
transferable from the Insured to any person unless the Company's written consent has been obtained. Notice should be given as soon as
practicable but not exceeding 30 days.

For policy wordings, please scan the QR code For Tata AIG General Insurance Company Ltd.

Signature Not Verified

Digitally signed by: Shammi Kapoor
Date: 2025.05.04 [Link] +05:30
Location: Mumbai
Authorized
Insurance is the subject matter of the solicitation. For more details on risk factors, terms Signatory
and conditions, please read sales brochure carefully before concluding a sale.
Tata AIG General
PolicyInsurance Company Limited.
servicing address
Regd Office: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013, Maharashtra, India.
2ND FLOOR ,SAMSON TOWERS 403 L PANTHEON ROAD EAGMORE,CHENNAI CHENNAI-600008 TAMIL NADU
Toll Free No. (24x7): 1800 266 7780 l Email: customersupport@[Link]
IRDA of India Registration No: 108 | Website: [Link] | CIN: U85110MH2000PLC128425 | PAN: AABCT3518Q | UIN: IRDAN108CP0011V02202122
 RECEIPT

Receipt No : 103001105611844 Receipt Date : 04/04/2025

Policy No : 2250035566

Received with thanks from URC CONSTRUCTION PVT LTD a sum of Rs. 12213( Rupees Twelve Thousand Two Hundred Thirteen And
Paise Zero Only)

[Link]. Policy Number Total Premium Utilized from the receipt for policy Balance
1 2250035566 12213.2 12213 12213

Note:
1. This is a computer generated receipt and does not require a signature.
2. Upon issuance of this Receipt, all previously issued temporary receipts, if any, related to this Policy shall be considered null and avoid.
3. Amounts received by cheque shall be subject to realisation.
4. Any amount received in excess of the Premium is being/shall be refunded by the Company.

GSTIN NO: GSTIN: 33AABCT3518Q1Z3-CHENNAI , SAC CODE: 997137

Revenue (Consolidated) Stamp Duty paid vide challan No. date for applicable cases

Insurance is the subject matter of the [Link] more details on risk factors, terms and conditions, please read salesbrochure carefully before concluding a sale.

TATA AIG General Insurance Company Limited

Registered office : Peninsula Business Park, Tower A,15th Floor, G.K Marg,Lower Parel, Mumbai-400013
24*7 Toll free Number : 1800 266 7780 Email : customersupport@[Link] website : [Link]
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 PAN : AABCT3518Q UIN : IRDAN108CP0011V02202122
 EMPLOYEES COMPENSATION INSURANCE
PROPOSAL FORM
If at any time during the Period of Insurance any Employee of the Insured so declared shall sustain injury by accident arising out of and in the
course of his employment in the Business, Indemnity shall be under Law(s) opted for, subject to the terms, exceptions and conditions contained
in the Policy wordings or endorsed hereon, upto the Limit of Indemnity against all sums for which the Insured shall be so liable which is agreed
by the Insurer and mentioned on the Policy Schedule
Proposer’s name in full : URC CONSTRUCTION PVT LTD

Proposer’s business [Correspondence] address: NCRTC PROJECT- LOT-P11 L2,NCRTC PROJECT- LOT-P11 L2,SECTOR-2, PANCHWATI ROAD,
SHATABDI NAGAR,,MEERUT-250103,MEERUT,UTTAR PRADESH

Proposer’s trade or occupation: As Per Annexure

Particulars of work to be covered in Detail:
CIVIL
Risk Location address(s) Location 1 As Mentioned in Condition, , , , MEERUT, 250103, MEERUT, UTTAR PRADESH, INDIA
Policy Period: From :04/04/2025 To 03/07/2025

COVERAGE’S REQUIRED

Coverage Scope of coverage Aggregate Limit of Indemnity Coverage Options (Yes/No]

Employees Subject otherwise, to the terms,conditions Limit: As per Employees Compensation Yes
Compensatin & Exclusions of the Policy, the amount of Act
liability incurred by the Insured.

Subject otherwise, to the terms,conditions Limit: As per Fatal Accident Act Yes
Fatal Accident & Exclusions of the Policy, the amount of
Act, 1855 liability incurred by the Insured.

a) Limit Per Employee for any number of Yes

accidents during Period of Insurance
Subject otherwise, to the terms,conditions Rs. Not applicable
Common Law & Exclusions of the Policy, the amount of
b) Limit Per Accident for any number of
liability incurred by the [Link] not
Employees [Link] applicable
exceeding:

c)Aggregate Limit for all accidentsand

claims arising there from during thePeriod
of Insurance Rs.750000000

d) Limit Per Employee for any number of

accidents during Period of Insurance
Medical Rs. 0
Expenses:
e) Aggregate liability for all accidents
during the Period of Insurance
Subject otherwise, to the terms,conditions Rs. 5000000
& Exclusions of the Policy, the amount of
liability incurred by the [Link] not Medical Expenses as per actual - Yes
exceeding:
Occupational
f) Limit Per Employee Rs. 0
Diseases

g)Aggregate liability of the company forall

employees during the Period of 0

Contractors Limit: As per Employees Compensation

Employees Act

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding a sale.
Tata AIG General Insurance Company Limited.
Regd Office: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013, Maharashtra, India.
Toll Free No. (24x7): 1800 266 7780 l Email: customersupport@[Link]
IRDA of India Registration No: 108 | Website: [Link] | CIN: U85110MH2000PLC128425 | PAN: AABCT3518Q | UIN: IRDAN108CP0011V02202122
 ALL PERSONS EMPLOYED MUST BE INCLUDED

*Wages means the remuneration payable to an Employee by the insured for the employment in the Business and includes any privilege or
benefit which is capable of being estimated in money other than a travelling allowance or the value of any travelling concession or a contribution
paid by the employer of a employee towards any pension or provident fund or a sum paid to a employee to cover any special expenses entailed
on him by the nature of his employment;

OWN EMPLOYEE DETAILS**

Declared Number of Total Declared Wages during

Description of Employees Place/Places of Employment
Employees the period of Insurance
As per Annexure As Per Annexure As Per Annexure As Per Annexure

Does the above, schedule include-

(a) All Persons in your service?
(b) All your contractors/subcontractors? YES

Do you comply with all statutory obligations, manufacturer’s recommendations and other
safety regulations in conduct of the Business.

Do you maintain an accurate record of the Employees and Wages in respect of the
Business in compliance with all statutory requirements.

Are you at present insured or have your ever proposed for an insurance in respect of your
liability to your employees? If so, please give the name of the Company or Companies.

Has any proposal for an insurance in respect of your liability to your employees or
renewal thereof ever been declined or withdrawn?

State the total Wages paid and particulars of accidents to your contractors employees during the past three years
Years [Past 3 years from this date] Wages Paid Amount of Loss

DECLARATION
I/We the undersigned this………..day of………….20…… desire to effect an insurance in terms of the Policy to be issued by the company
against my/our Statutory, Common Law liability and other covers above mentioned.
I/We hereby declare that all the above statements and particulars, which I/We have read over, checked, are true that I/We have not suppressed
misrepresented or mis-stated any material fact, that I/We have fairly declared my/our total wages and salaries expenditure and I/We agree that
this declaration shall be the basis of the contract between me/us and the ………………………………..Company.
I/We also agree to inform Company any changes in any respect of any material matter to the grant of a cover in this proposal
form/documents/risk proposed for insurance after the submission of this Proposal form.
I/We also agree that the contract of Insurance will be effective only upon Company conveying its acceptance of this proposal, and Company
actually receiving or realizing [in case of payment by cheque/DD/PO] of prescribed premium amount, falling which Company’s risk is void ab initio.
I/We undertake to exercise all statutory, ordinary and reasonable precautions for safety of all the Employees as if they were uninsured.

Date: 04/04/2025 Signature of Proposer URC CONSTRUCTION PVT LTD

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding a sale.
Tata AIG General Insurance Company Limited.
Regd Office: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013, Maharashtra, India.
Toll Free No. (24x7): 1800 266 7780 l Email: customersupport@[Link]
IRDA of India Registration No: 108 | Website: [Link] | CIN: U85110MH2000PLC128425 | PAN: AABCT3518Q | UIN: IRDAN108CP0011V02202122
 Declaration by Proposer
I/We hereby declare that the statements made by me/us herein and in the attachments hereto are true to the best of my knowledge and belief and I/We hereby agree
that this Proposal shall from the basis of the insurance contract between me/us and Tata AIG General Insurance Company Limited (referred as the Company). I/We
further confirm that if any additions or alterations are carried out in the risk proposed for insurance hereinafter the submission of this proposal then particulars of such
shall be forthwith conveyed to the Company. I/We further agree that the submission of this Proposal to the Company and its receipt there of shall not constitute an
acceptance of risk by the Company.
The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained to me. I/we have understood these and confirm to
abide by the policy terms & conditions
Signature of the Proposer: __________________________________________________________________________

Name & Signature of agent/intermediary:

___________________________________________________________________________________________________________________________________________
___________ Code: _____________________

Vernacular Declaration (Certification in case the proposer has signed in vernacular/thumb print):

The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained by me in vernacular to the proposer who has
understood and confirmed the same.
Signature/Thumb impression of the Proposer: _________________________________________________________

Name & Signature of agent/intermediary:

___________________________________________________________________________________________________________________________________________
________________________________________

AML Guidelines
I/we hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been/will be paid out of proceeds of crime related to any
of the offence listed in Prevention of Money Laundering Act, 2002. I understand that the Company has the right to call for documents to establish sources of funds.
The insurance company has right to cancel the insurance contract in case I am/ have been found guilty by any competent court of law under any of the statutes,
directly or indirectly governing the prevention of money laundering in India

Nationality : Indian Non-Indian If Non-Indian, please specify Country : _______________________

Type of Organization Cooperatives Governments Non Governmental Organizations Society
Trust Partnership International Organization
Corporations Section 25 Company

Intermediary Declaration
I,____________________ (Full Name) in my capacity as an Insurance Advisor/ Specified Person of the Corporate Agent/Authorized employee of the
Broker/Relationship Officer, do hereby declare that I have explained all the contents of this Proposal Form, including the nature of the questions contained in this
Proposal Form to the Proposer including statements, information and response(s) submitted by him /her in this Proposal Form to questions contained herein or any
details sought herein will form the basis of the Contract of Insurance between the Company and the Proposer, if this Proposal is accepted by the Company for
issuance of the Policy. I have further explained that if any untrue statements/information/response(s) is/are contained in this Proposal Form/including addendums,
affidavits, statement, submissions, furnished/to be furnished, the Company shall have the right to vary the benefits which may be payable and further more if there
has been a non – disclosure of any material fact, the policy issued to his/her favor pursuant to this Proposal may be treated by the Company as null and void and
all premiums paid under the policy may be forfeited to the Company

License No.(Intermediary/Corporate Agent/Broker/Relationship Office) __________________________

Name of the specified person and code _______________________

Place : ____________
Date : _____________ Signature of Intermediary

I/We the undersigned this ___ of ___ desire to effect an insurance in terms of the Policy to be issued by the Company against my/our Statutory and Common Law
Liability.I/We agree to render, at the end of each period of Insurance, a statement in the form required by the Company of all wages actually paid, and to pay
premium on any wages paid in excess of the amount estimated above, I/We hereby declare that all the above statements and particulars which I/We have read over
checked, are true that I/We have not suppressed misrepresented or mis stated any material fact, that I/We have fairly estimated my/our total wages and salaries
expenditure and I/We agree that this declaration shall be the basis of the contract between me/us and the Company.

Date : Signature of Propose

Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015
1. No person shall allow or offer to allow either directly or indirectly as inducement to any Person to take or renew or continue an Insurance in respect of any
kind of 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, not
shall any person taking out or renewing or continuing a Policy accept such a rebate except such rebate as may be allowed in accordance with the published
prospectuses or tables of the Insurer

2. Any Person making default in complying with the provision of this section shall be punishable with fine which may extend to Ten Lakh Rupees.
Section 64 VB of the Insurance Act 1938 Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance Company
Limited.
Disclaimer: Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms and conditions, please refer sales brochure /
policy wordings carefully, before concluding a sale.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding a sale.
Tata AIG General Insurance Company Limited.
Regd Office: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013, Maharashtra, India.
Toll Free No. (24x7): 1800 266 7780 l Email: customersupport@[Link]
IRDA of India Registration No: 108 | Website: [Link] | CIN: U85110MH2000PLC128425 | PAN: AABCT3518Q | UIN: IRDAN108CP0011V02202122
 ANNEXURE "W" to COVERAGE SECTION "W"
Attached to and forming part of the Policy No. 2250035566

Insured: URC CONSTRUCTION PVT LTD

Annexure Format for Unnamed policy type :

Description of work done by Declared Number of Declared Wages during the

Place/Places of Employment
Employees Employees Period of Insurance
As Mentioned in Condition
250103UTTAR
WORKERS 50 22,50,000
PRADESHMEERUTMEERUT,UTTA
R PRADESH
Total 50 22,50,000

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding a sale.
Tata AIG General Insurance Company Limited.
Regd Office: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013, Maharashtra, India.
Toll Free No. (24x7): 1800 266 7780 l Email: customersupport@[Link]
IRDA of India Registration No: 108 | Website: [Link] | CIN: U85110MH2000PLC128425 | PAN: AABCT3518Q | UIN: IRDAN108CP0011V02202122
 ENDORSEMENTS
Coverage for Medical Expenses

Policy No.:2250035566
Insured: URC CONSTRUCTION PVT LTD

In consideration of the payment of an additional premium it is hereby understood and agreed that this Policy is extended to cover Insured’s
liability towards medical expenses for treatment of Injury arising out of accident in respect of which indemnity granted under this Policy
otherwise applies

Subject to otherwise to the terms, provisions and conditions of the within Policy.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding a sale.
Tata AIG General Insurance Company Limited.
Regd Office: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013, Maharashtra, India.
Toll Free No. (24x7): 1800 266 7780 l Email: customersupport@[Link]
IRDA of India Registration No: 108 | Website: [Link] | CIN: U85110MH2000PLC128425 | PAN: AABCT3518Q | UIN: IRDAN108CP0011V02202122