THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

COLLECTION RECEIPT CUM ADJUSTMENT VOUCHER

Issuing Office : DO-IV (230400)
Address : 2ND FLOOR, KIRAN CHAMBERS, OPP J K TOWER
SUB JAIL CROSSING,
RING ROAD,395002
SURAT
Insured Pan Number : AZUPG2527K
Phone : 2336864
Email : nia.230400@newindia.co.in
Fax : 2313467
Collection Number : 23040081220000024515
Collection Date : 04/02/2023
Business Source Code : 1D3937247
PAN No of Payer : AZUPG2527K

Received with thanks from HIRENSINH MANHARSINH GOHIL.

The amount received/Adjusted is towards -

Policy No. A/C Description Amount` A/C Code Sub A/C Code
23040034222800012763 Bank-230400 19452.00 9100.230400 BA00006502-230400-9100
Total = ` 19452.00

Your Payment/Adjustment Details are as under -

Mode Amount ` Cheque Cheque Date Drawee Bank Drawee Branch Reference No. Scroll/BG/A
No. PD Balance
Cheque 19452.00 000026 04-FEB-23 HDFC BANK LTD SURAT 2304002210073256 N.A.
Total = ` 19452.00

Utilization details of the Collected Amount :

Premium GST Stamp Duty Excess Amount
16484.00 2968.00 0.00 0
Sl no. Agency Code Agency Name Department Code
1 NIAAG00029314 SMIT DEVANG SARAIYA 34

For The New India Assurance Company Limited

Revenue Stamp
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Date of Issue: 04/02/2023

(MR. JAGDISH
SURATI)
[SR. DIV MANAGER]

Cashier's Initial Authorized Signatory

Note -
1.Please note the Policy Number, Collection Number and date in all future correspondence.This Receipt is subject to Realisation of
Cheque..
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.

Signature Not
Verified
Digitally signed
by JAGATJAYEE
PANIGRAHI
Date: 2023.02.04
13:50:23 IST
Policy No. : 23040034222800012763Document generated by AG_SMITH14 at 04/02/2023 13:50:22 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)

We hereby declare that though our aggregate turnover in any preceding financial year from
2017-18 onwards is more than the aggregate turnover notified under sub-rule (4) of rule 48,
we are not required to prepare an invoice in terms of the provisions of the said sub-rule.

Tax Invoice No : 23040022E0039036

IRDA Registration Number: 190

NIA PAN NUMBER: AAACN4165C

Policy No. : 23040034222800012763Document generated by AG_SMITH14 at 04/02/2023 13:50:22 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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