| [Regulations 3, 5, 6 and 14] |
| FORM A |
| [Regulation 3(1)(a)] |
| MOTOR VEHICLES INSURANCE (THIRD-PARTY RISKS) REGULATIONS |
| CERTIFICATE OF INSURANCE |
| Certificate No. | Policy No. |
| 1. | Index mark and registration number of vehicle | |
| 2. | Name of policy holder | |
| 3. | Date of the commencement of insurance | |
| 4. | Date of expiry of insurance | |
| 5. | Persons or classes of persons entitled to drive | |
| 6. | Limitation as to use* | |
| I/We hereby certify that the policy to which this certificate relates is issued in accordance with the provisions of the Motor Vehicles Insurance (Third-party Risks) Act. |
| ______________________ |
| Date of issue |
| ______________________ |
| Time of issue |
| ______________________ |
| INSURER |
| * Limitations rendered inoperative by section 11 of the Motor Vehicles Insurance (Third-party Risks) Act are not to be included under this heading. |