THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

COLLECTION RECEIPT CUM ADJUSTMENT VOUCHER

Issuing Office : DOMBIVILI DO (170700) (170700)
Address : RAGHUKUL HEIGHTS,ABOVE JAOLI BANK
1ST FLOOR, DR. RAJENDRA PRASAD ROAD,
DOMBIVALI (E),421201
DOMBIVALI
Phone : 02512862639
Email : nia.170700@newindia.co.in
Fax : 02512862638
Collection Number : 10000089200800328088
Collection Date : 19/08/2020
Business Source Code : 2D5610812
PAN No of Payer : AFRPJ5009A

Received with thanks from MILIND ANANT JOSHI.

The amount received/Adjusted is towards -

Policy No. A/C Description Amount` A/C Code Sub A/C Code
17070034202700000445 Bank-100000 11759.00 9100.100000 BA00013647-100000-9100
Total = ` 11759.00

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 11759.00 SBOM91 N.A. N.A. N.A. 1707002010019017 N.A.
Credit 3064
Advice 7141
Total = ` 11759.00

Utilization details of the Collected Amount :

Premium GST Stamp Duty Excess Amount
9965.00 1794.00 0.00 0
Sl no. Agency Code Agency Name Department Code
1 NIA2D5610630 ANANT B.BABAR 34

For The New India Assurance Company Limited

Revenue Stamp
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Date of Issue: 19/08/2020

(Mr. KISHOR PATIL)

[Sr. Div. 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 : 17070020P0012109

IRDA Registration Number: 190

Signature Not
Verified
Digitally signed
by Srinivasan
Vaideswaran
Date: 2020.08.19
13:05:20 IST
Policy No. : 17070034202700000445Document generated by QR_RENEWAL at 19/08/2020 13:05:15 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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