THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

COLLECTION RECEIPT CUM ADJUSTMENT VOUCHER

Issuing Office : CHIPLUN DO (170900)
Address : BLOCK NO 40 2ND FLOOR, AJINKYA ARCADE,CHINCHNAKA

,415605
CHIPLUN
Insured Pan Number :
Phone : 2355253903
Email : nia.170900@newindia.co.in
Fax :
Collection Number : 17090081230000071175
Collection Date : 18/03/2024
Business Source Code : BR00000289
PAN No of Payer :

Received with thanks from SIRAZUL HOQUE.

The amount received/Adjusted is towards -

Policy No. A/C Description Amount` A/C Code Sub A/C Code
17090031230200070243 Bank-170900 843.00 9100.170900 BA00018268-170900-9100
Total = ` 843.00

Your Payment/Adjustment Details are as under -

Mode Amount ` Cheque Cheque Date Drawee Bank Drawee Branch Reference No. Scroll/BG/A
No. PD Balance
ECS 843.00 YEP7227 N.A. N.A. N.A. 1709002313841318 N.A.
429
3384
Total = ` 843.00

Utilization details of the Collected Amount :

Premium GST Stamp Duty Excess Amount
714.00 129.00 0.00 0
Sl no. Agency Code Agency Name Department Code
1 NA QUICKINSURE INSURANCE BROKERS PVT LTD 31

For The New India Assurance Company Limited

Revenue Stamp
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Date of Issue: 18/03/2024

(Mr. Samson Jerrod

John)
[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.

Signature Not
Verified
Digitally signed
by DHIRAJ
KUMAR
Date: 2024.03.18
14:19:37 IST
Policy No. : 17090031230200070243Document generated by QUICKINSR at 18/03/2024 14:19:21 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 : 17090023P0075710

IRDA Registration Number: 190

NIA PAN NUMBER: AAACN4165C

Policy No. : 17090031230200070243Document generated by QUICKINSR at 18/03/2024 14:19:21 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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