THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

COLLECTION RECEIPT CUM ADJUSTMENT VOUCHER

Issuing Office : CDU-2, AHMEDABAD (210200)
Address : 2 FLOOR, NANALAL BUILDING, ASHRAM RAOD, AHEMDABAD

,380009
AHMEDABAD
Phone : 07926589384
Email : nia.210200@newindia.co.in
Fax : 07926589464
Collection Number : 10000089190800134076
Collection Date : 13/08/2019
Business Source Code : 1D6341876
PAN No of Payer : AOBPJ5639M

Received with thanks from VISHAL P. JARIWALA.

The amount received/Adjusted is towards -

Policy No. A/C Description Amount` A/C Code Sub A/C Code
21020034192700000309 Bank-100000 5717.00 9100.100000 BA00013647-100000-9100
Total = ` 5717.00

Your Payment/Adjustment Details are as under -

Mode Amount ` Cheque Cheque Date Drawee Bank Drawee Branch Reference No. Scroll/BG/A
No. PD Balance
EPG 5717.00 QSBI786 N.A. N.A. N.A. 2102001910028661 N.A.
Credit 739
Advice 6403
Total = ` 5717.00

Utilization details of the Collected Amount :

Premium GST Stamp Duty Excess Amount
4845.00 872.00 0.00 0
Sl no. Agency Code Agency Name Department Code
1 NIA1D6334439 MR.KAUSHIK SURESHBHAI CHAUHAN 34

For The New India Assurance Company Limited

Revenue Stamp
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Date of Issue: 13/08/2019

(MR.
MAHENDRAKUMAR
VIRAMJI SONARA)
[DIVISIONAL
MANAGER]

Cashier's Initial Authorized Signatory

Note -
1.Please note the Policy Number, Collection Number and date in all future correspondence. .
2.NIA shall not be liable for any claim arising out of sales made during the period between the due date and date of payment of the
installment if the premium paid has been exhausted by turnover declarations/if there is insufficient premium balance.

Tax Invoice No : 21020019E0016592

IRDA Registration Number: 190

Signature Not
Verified
Digitally signed
by Srinivasan
Vaideswaran
Date: 2019.08.13
12:38:01 IST
Policy No. : 21020034192700000309Document generated by CUST798076 at 13/08/2019 12:37:57 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)

Policy No. : 21020034192700000309Document generated by CUST798076 at 13/08/2019 12:37:57 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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