THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

THE NEW INDIA ASSURANCE CO. LTD.

REGISTERED & HEAD OFFICE:87,MAHATMA GANDHI ROAD,MUMBAI
400001

Customer ID : 1H2339427

New India Mediclaim POLICY

SCHEDULE

Insureds Details Issuing Office Details

Insured Name : MR. BIDHAN MUKHERJEE Office Code : CALCUTTA DO-9 (510900)
Address : 26/1, UMESH MUKHERJEE ROAD, Address : GUHA ESTATE,2ND FLOOR, 7,GANESH
BELGHARIA, KOLKATA. DIST. : CHANDRA AVENUE
KOLKATA, WEST BENGAL
,700013

KOLKATA ,WEST BENGAL, 700056

Phone No/Mobile No. : 8777483986, 033-25233574, 9002075835 Phone No : 03322372591
E-mail/Fax : bidhanmukherjee64@gmail.com, / E-mail/Fax : nia.510900@newindia.co.in /
PAN No : ANUPM9491L S.Tax Regn. No : AAACN4165CST178
GSTIN/UIN : NA / NA GSTIN : 19AAACN4165C1ZO
: SAC : 997139 (Other non-life insurance services
excl RI)

Policy Details
Business Source Code
Policy Number : 51090034199500000454 Dev.Off : MR. DEBASISH SAHA
level./Broker/Direct (1D10775183)
Period of Insurance : From:24/06/2019 12:00:01 AM Agent/Bancassurance : Mr. GOUTAM DAS (224)
To:23/06/2020 11:59:59 PM (1D10772360)
Prev. Policy no. : 51090034189500000547 Phone No : 9433010352 / 9830840403
Client Type : Non-Corporate E-mail/Fax : goutamdaslici@gmail.com, /
nil_suvo@yahoo.com, / /

Insured Person Details

Sl. No. Name of Date of Birth Sex Occupation Relation Pre-Existing Disease Sum Insured Cumulative
Insured Bonus Buffer
Person
1 MR. BIDHAN 08/08/1964 M Any Othe Proposer NA 500000 36250
MUKHERJEE r
2 MRS. 12/03/1968 F Housewiv Spouse NA 500000 36250
MONIDIPA es
MUKHERJEE
MRS.
MONIDIPA
MUKHERJEE

Details Of TPA for New India Mediclaim Policy (Notice or Communication to be given in respect of claim)
Name : HERITAGE HEALTH INSURANCE TPA Telephone : 03322482784
PVT LTD
Address : NICCO HOUSE, 5TH FLR, 2 HARE Fax :
STREET Email :
NA Toll Free No. :
Mobile No. : 3322486430

Name of Nominee : MONIDIPA MUKHERJEE. Relation : Spouse

Optional Cover Table

Sl. Name of the person Optional Cover I - No Optional Cover II- Maternity Optional Cover III- Revision Optional Cover
No. Proportionate Deduction Expenses Benefit (Sum in Cataract Limit IV- Voluntary
Insured): Co-pay

1 MR. BIDHAN Not Opted Not Opted NA Not Opted NA Not Opted
MUKHERJEE

Signature Not
Verified
Digitally signed
by Srinivasan
Vaideswaran
Date: 2019.06.09
10:35:47 IST
Policy No. : 51090034199500000454Document generated by QR_RENEWAL at 09/06/2019 10:35:45 Hours.
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.

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THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

2 MRS. MONIDIPA Not Opted Not Opted NA Not Opted NA Not Opted
MUKHERJEE MRS.
MONIDIPA
MUKHERJEE

Previous Policy Details

Sl. No. Name of Insured Previous Policy No. Previous Sum Cumulativ Effective Pre-existing Disease
Insured details e bonus Date
buffer
1 MR. BIDHAN MUKHERJEE 510900341895000005 200000 36250 24/06/200 NA
47 8
2 MRS. MONIDIPA 510900341895000005 200000 36250 24/06/200 NA
MUKHERJEE MRS. 47 8
MONIDIPA MUKHERJEE

Sl. Name of Insured Basic Premium Premium for Optional Premium for Prem Discount for Total
No. Cover I Optional ium Optional Premium
Cover II for Cover IV
Optio
nal
Cove
r III
1 MR. BIDHAN 14418 0 0 0 0 14418
MUKHERJEE
2 MRS. MONIDIPA 14418 0 0 0 0 14418
MUKHERJEE MRS.
MONIDIPA MUKHERJEE
Total Premium 28836
GST 5190
Total Amount 34026
Net Premium Amt.(In words) RUPEES THIRTY-FOUR
THOUSAND TWENTY-SIX ONLY

*This Policy is subject to terms and conditions of New India Mediclaim.

Premium and GST Details

Rate of Tax Amount in INR
Premium `28836
SGST 9 2595
CGST 9 2595
IGST 0 0

IN WITNESS WHEREOF,the undersigned being duly authorized has hereunto set his/her hand

at ______________ this _______________ day of _______________ 20

Policy No. : 51090034199500000454Document generated by QR_RENEWAL at 09/06/2019 10:35:45 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.

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THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

Date of Issue: 09/06/2019

(Mr. SREEKANTA PATRA)

[Div. Manager]
Authorized Signatory For and on behalf of
The New India Assurance Company
Limited

Policy No. : 51090034199500000454Document generated by QR_RENEWAL at 09/06/2019 10:35:45 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.

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THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

Insurer Office Code : CALCUTTA DO-9 (510900)

Address : GUHA ESTATE,2ND FLOOR, 7,GANESH
CHANDRA AVENUE

,700013
Telephone : 03322372591
Fax :

New India Mediclaim

PREMIUM CERTIFICATE FOR THE PURPOSE OF DEDUCTION UNDER SECTION 80 D OF INCOME TAX ( AMENDMENT ) ACT 1986

This is to certify that Mr./Mrs. MR. BIDHAN MUKHERJEE has paid ` RUPEES THIRTY-FOUR THOUSAND TWENTY-SIX ONLY (in
words) towards premium for New India Mediclaim for the period 24/06/2019 12:00:01 AM to 23/06/2020 11:59:59 PM

Policy no. : 51090034199500000454

Receipt no. & date : 10000089190600063134
09/06/2019

Date of Issue: 09/06/2019

(Mr. SREEKANTA PATRA)

[Div. Manager]
Authorized Signatory For and on behalf of
The New India Assurance Company
Limited
(Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation
of the policy or any alteration in the Insurance affecting the premium)

Policy No. : 51090034199500000454Document generated by QR_RENEWAL at 09/06/2019 10:35:45 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.

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 THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

IMPORTANT

This policy is subject to the terms and conditions contained in the policy document (Clauses).

This policy is governed by Health Insurance Regulations 2016 issued by Insurance Regulatory
Development Authority of India on 12.07.2016.

This policy is also governed by IRDAI (Protection of Policyholders' Interest) Regulations, 2017.

This Schedule comes attached with the policy document (Clauses). If not attached, please ask for the
same.

Health Insurance Regulations 2016 and IRDAI (Protection of Policyholders' Interest) Regulations, 2017 are
available on the website of IRDAI.

Tax Invoice No : 51090019P0001710

IRDA Registration Number: 190

Policy No. : 51090034199500000454Document generated by QR_RENEWAL at 09/06/2019 10:35:45 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.

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