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 : PO07012737

New India Mediclaim POLICY

SCHEDULE

Insureds Details Issuing Office Details

Insured Name : MR.POOJARY SHIVARAM Office Code : MALLESWARAM BRANCH (671601)
Address : NO.7/7, ''PRATHAMESH'', Address : NO.124, 2ND FLOOR,'GANESH
S.G.COMPOUND, GOWDANAPALYA, TOWERS',
PADMANABHA NAGAR, BETWEEN 10TH & 11TH CROSS,
MARGOSA ROAD,
BANGALORE ,KARNATAKA, 560061 MALLESHWARAM,,560003
Phone No/Mobile No. : 9740319020 Phone No : 08023440607 / 08023469336
E-mail/Fax : Shivaram_poojary@yahoo.com, / E-mail/Fax : nia.671601@newindia.co.in /
08023346367
PAN No : S.Tax Regn. No : AAACN4165CST178
GSTIN/UIN : NA / NA GSTIN : 29AAACN4165C2ZM
: SAC : 997139 (Other non-life insurance services
excl RI)

Policy Details
Business Source Code
Policy Number : 67160134189500000776 Dev.Off : DIRECT BUSINESS (1D7821577)
level./Broker/Direct
Period of Insurance : From:08/02/2019 12:00:01 AM Agent/Bancassurance : Mrs. MEENAKSHI B S (AG00011378)
To:07/02/2020 11:59:59 PM
Prev. Policy no. : 67160134162500001358 Phone No : 9481806452 / 23440607, 23469336,
Client Type : Non-Corporate E-mail/Fax : pranavgopal@gmail.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.POOJARY 20/04/1967 M Professi Proposer NA 300000 75000
SHIVARAM onal/Adm
inistrat
ive/Mana
gerial
2 NAVEENA 27/07/1973 F Professi Spouse NA 100000 5000
LATHA onal/Adm
inistrat
ive/Mana
gerial
3 NEHAL 30/09/2003 F Professi Children NA 100000 26250
onal/Adm
inistrat
ive/Mana
gerial
4 SONAL 08/05/2008 F Professi Children NA 100000 20000
onal/Adm
inistrat
ive/Mana
gerial

Details Of TPA for New India Mediclaim Policy (Notice or Communication to be given in respect of claim)
Name : MEDI ASSIST INSURANCE TPA PVT. Telephone : 18002089449
LTD.
Address : MEDI ASSIST INDIA TPA PVT. LTD., Fax : 18004259559
TOWER D, FOURTH FLOOR, Email :
IBC KNOWLEDGE PARK, 4/1, Toll Free No. :
BANNERGHATTA ROAD, Mobile No. : 8049698000
BANGALORE
Signature Not
Verified
Digitally signed
by Srinivasan
Vaideswaran
Date: 2019.02.06
18:42:51 IST
Policy No. : 67160134189500000776Document generated by QR_RENEWAL at 06/02/2019 18:42:50 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)

Name of Nominee : MRS.NAVEENA LATHA 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.POOJARY Not Opted Not Opted NA Not Opted NA Not Opted

SHIVARAM
2 NAVEENA LATHA Not Opted Not Opted NA Not Opted NA Not Opted
3 NEHAL Not Opted Not Opted NA Not Opted NA Not Opted
4 SONAL Not Opted Not Opted NA Not Opted NA Not Opted

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 NEHAL 671601341795000004 100000 26250 07/02/200 NA
98 7
2 SONAL 671601341795000004 100000 20000 07/02/200 NA
98 7
3 NAVEENA LATHA 671601341795000004 100000 5000 07/02/200 NA
98 7
4 MR.POOJARY SHIVARAM 671601341795000004 300000 75000 07/02/200 NA
98 7

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.POOJARY SHIVARAM 10808 0 0 0 0 10808
2 NAVEENA LATHA 2867 0 0 0 0 2867
3 NEHAL 2708 0 0 0 0 2708
4 SONAL 2708 0 0 0 0 2708
Total Premium 19091
GST 3436
Total Amount 22527
Net Premium Amt.(In words) RUPEES TWENTY-TWO
THOUSAND FIVE HUNDRED
TWENTY-SEVEN ONLY

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

Premium and GST Details

Rate of Tax Amount in INR
Premium `19091
SGST 9 1718
CGST 9 1718
IGST 0 0

Policy No. : 67160134189500000776Document generated by QR_RENEWAL at 06/02/2019 18:42:50 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)

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

at ______________ this _______________ day of _______________ 20

Date of Issue: 06/02/2019

(MRS. G S ANNAPURNAMMA)
[SR BRANCH MANAGER]
Authorized Signatory For and on behalf of
The New India Assurance Company
Limited

Policy No. : 67160134189500000776Document generated by QR_RENEWAL at 06/02/2019 18:42:50 Hours.

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

Page 3 of 5
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

Insurer Office Code : MALLESWARAM BRANCH (671601)

Address : NO.124, 2ND FLOOR,'GANESH TOWERS',
BETWEEN 10TH & 11TH CROSS,
MARGOSA ROAD, MALLESHWARAM,,560003
Telephone : 08023440607 / 08023469336
Fax : 08023346367

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.POOJARY SHIVARAM has paid ` RUPEES TWENTY-TWO THOUSAND FIVE HUNDRED TWENTY-
SEVEN ONLY (in words) towards premium for New India Mediclaim for the period 08/02/2019 12:00:01 AM to 07/02/2020
11:59:59 PM

Policy no. : 67160134189500000776

Receipt no. & date : 10000089180200068495
06/02/2019

Date of Issue: 06/02/2019

(MRS. G S ANNAPURNAMMA)
[SR BRANCH 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. : 67160134189500000776Document generated by QR_RENEWAL at 06/02/2019 18:42:50 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 : 67160118P0002203

IRDA Registration Number: 190

Policy No. : 67160134189500000776Document generated by QR_RENEWAL at 06/02/2019 18:42:50 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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