THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

Personal Accident Insurance ((Individual))

UIN Number -
Insured Name : SHAMBHU PANDIT .
Insured's Details Issuing Office Details
Customer ID : PO85997828 Office Code : MALDA D.O. (513000)
Address : TALPAHARI, PS - LITTIPARA, DIST - Address : 21/22, RABINDRA AVENUE,MALDA
PAKUR
,732101

HIRANPUR ,JHARKHAND, 816104

Phone No : Phone No : 03512253471
E-mail/Fax : / E-mail/Fax : nia.513000@newindia.co.in /
PAN No : S.Tax Regn. No : AAACN4165CST178
GSTIN/UIN : NA / NA GSTIN : 19AAACN4165C1ZO
: SAC : 997139 (Other non-life insurance
services excl RI)

Policy Details
Policy Number : 51300042200100000139 Business Source Code
Period of Insurance : From:24/12/2020 12:00:01 AM To: Dev.Off level./Broker/Corp. : Mr. MR KRIPA SINDHU DAS -
23/12/2021 11:59:59 PM Agent/IMF/POS/Web (DE00003508)
Aggregator

Date of Proposal : 24-Dec-20 Agent/Bancassurance/Spe : Mr. SOMNATH DAS

cified Person (NIAAG00122005) SOMNATH DAS
(SI00207473)
Prev. Policy no. : Phone No :
Client Type : Non-Corporate E-mail/Fax : disharockz98@gmail.com, / / /
Staff Discount : No Type of Cover : NA

Premium: GST: Total (`) Stamp Duty Rupees (in words) Receipt No. & Date:
` 508 ` 91 ` 599 `15 RUPEES FIVE 5130008120000001
HUNDRED NINETY- 4658 - 22/12/20
NINE ONLY

Details of the Insured and/other Family members covered under the Policy: INDIVIDUAL
Sl. No Name of the Age Occupation Relation Medical Sum Risk Group
Insured Extension Insured
1 SHAMBHU PANDIT 26 Persons engaged Self Yes 282000 Risk Group I
in administrative
functions

Sl. No Cumulative Bonus Assignee Details Physical Excess War & Allied Cover opted
Defects/
Details
Amount Name Relation Sum Country Type of
Insured Period
1 0 AMULYA FATHER No / NA 0 0 NA NA
PANDIT

Table Details: (Individual)

Sl.No Table A Table B Table C Table D
Table A Sum Insured Table B Sum Insured Table C Sum Insured Table D Sum Insured
1 Yes 282000 No 0 No 0 No 0

Sl.No Special Conditions

1 NA

Signature Not
Verified
Policy No. : 51300042200100000139Document generated by 39453 at 22/12/2020 23:39:07 Hours.
Digitally signed
by Srinivasan Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Vaideswaran Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.
Date: 2020.12.22
For redressal
23:39:07 IST of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with our own
grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please visit our website
http://newindia.co.in.

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

Premium and GST Details

Rate of Tax Amount in INR
Premium ` 508.00
SGST 0 0
CGST 0 0
IGST 18 91

The Policy Shall be subject to PERSONAL ACCIDENT INSURANCE ((Individual)) policy clauses attached herewith IN WITNESS
WHEREOF the undersigned duly authorized hereinto set his hand

Place:- For and on behalf of

Date:- The New India Assurance Company Limited

Duly Constituted Attorney(s)

Mudrank_____________Dt.___________consolidated Stamp Fees Paid by Pay Order Number_______________vide receipt

number___________dt.__________.

Stamp Duty under the Policy is `

Tax Invoice No : 51300020P0012868

IRDA Registration Number: 190

Policy No. : 51300042200100000139Document generated by 39453 at 22/12/2020 23:39:07 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.
For redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with our own
grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please visit our website
http://newindia.co.in.

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