THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

ADJUSTMENT VOUCHER
Issuing Office : HOSANGABAD MO (452404)
Address : 19, SHANTI NAGAR, GROUND FLOOR,ITI ROAD, HOSANGABAD

,461001
HOSHANGABAD
Phone : 07574257762
Email : sk.gangrade@newindia.co.in
Fax : 8770962510
Collection Number : 45240481180000005678
Collection Date : 15/11/2018
Business Source Code : DI00000849
PAN No of Payer :

Received with thanks from BHUPENDRA SINGH SH.

The amount received/Adjusted is towards -

Policy No. A/C Description Amount` A/C Code Sub A/C Code
45240431180100005988 Cash Deposit 1997.00 5076.452404 CD0000426913
Account-452404
Total = ` 1997.00

Your Payment/Adjustment Details are as under -

Mode Amount ` Cheque Cheque Date Drawee Bank Drawee Branch Reference No. Scroll/BG/A
No. PD Balance
Advance 1997.00 N.A. N.A. N.A. N.A. 4524041810008933 21120.00
Premium
Deposit
Total = ` 1997.00

Utilization details of the Collected Amount :

Premium GST Stamp Duty Excess Amount
1693.00 304.00 0.00 0
Sl no. Agency Code Agency Name Department Code
1 NIA1D12631864 MR. SANJAY CHOUKSEY 31

For The New India Assurance Company Limited

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Date of Issue: 15/11/2018

(Mr. Sanjay Gangrade)

[Admin. Officer]

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 : 45240418E0001261

IRDA Registration Number: 190

Signature Not
Verified
Digitally signed
by Srinivasan
Vaideswaran
Date: 2018.11.15
19:25:38 IST
Policy No. : 45240431180100005988Document generated by AG_SANJA64 at 15/11/2018 19:25:34 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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