THE NEW INDIA ASSURANCE CO. LTD.

(Wholly owned by the Govt. of India)

Personal Accident Insurance ((Individual))

UIN Number -
Insured Name : JAGMOHIT PAL SINGH
Insured's Details Issuing Office Details
Customer ID : PO58375872 Office Code : BO UNDER DO-1,SECTOR-17-A
(350106)
Address : #3159B,SECTOR 39-D,CHANDIGARH Address : LIC BUILDING,2ND FLOOR, SECTOR
17-B, CHANDIGARH

CHANDIGARH CITY ,CHANDIGARH, ,160017

160001
Phone No : 9501017540 Phone No : NA
E-mail/Fax : / E-mail/Fax : nia.350106@newindia.co.in /
PAN No : S.Tax Regn. No : AAACN4165CST178
GSTIN/UIN : NA / NA GSTIN : 04AAACN4165C1ZZ
: SAC : 997139 (Other non-life insurance
services excl RI)

Policy Details
Policy Number : 35010642170100000188 Business Source Code
Period of Insurance : From:19/03/2018 03:17:08 PM To: Dev.Off : SH.SIMARJEET SINGH DHILLON -
18/03/2019 11:59:59 PM level./Broker/Corp. (DE7835897)
Agent/IMF/POS
Date of Proposal : 19-Mar-18 Agent/Bancassurance : MR. MANJIT SINGH
(NIA1D7832488)
AGENT_SITE_11043 (1D7836397)
Prev. Policy no. : PU0 Phone No : 9855860013 / 9417038264
Client Type : Non-Corporate E-mail/Fax : singhmanjit180@gmail.com, /
ss.dhillon@newindia.co.in,
ss.dhillon@newindia.co.in / /
Staff Discount : No Type of Cover : NA

Premium: GST: Total (`) Stamp Duty Rupees (in words) Receipt No. & Date:
` 90 ` 16 ` 106 `10 RUPEES ONE 3501068117000000
HUNDRED SIX ONLY 9912 - 19/03/18

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 JAGMOHIT PAL SINGH 20 Student Self No 200000 Risk Group I

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 DR.MANIND FATHER No / NA 0 0 NA NA
ER SINGH

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 No 0 No 0 No 0 Yes 200000

Sl.No Special Conditions

1 AS PER PA POLICY

Premium and GST Details

Rate of Tax Amount in INR

Signature Not
Verified
Digitally signed
by Srinivasan Policy No. : 35010642170100000188Document generated by 31310 at 19/03/2018 15:57:16 Hours.
Vaideswaran Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Date: 2018.03.19
For 15:57:17
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
IST
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.

Page 1 of 2
 THE NEW INDIA ASSURANCE CO. LTD.
(Wholly owned by the Govt. of India)

Premium ` 90.00
SGST 9 8
CGST 9 8
IGST 0 0

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 : 3501064201000188

IRDA Registration Number: 190

Policy No. : 35010642170100000188Document generated by 31310 at 19/03/2018 15:57:16 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
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.

Page 2 of 2