THE NEW INDIA ASSURANCE CO. LTD.

(Wholly owned by the Govt. of India)

THE NEW INDIA ASSURANCE CO. LTD.

REGISTERED & HEAD OFFICE:87,MAHATMA GANDHI ROAD,MUMBAI
400001

Customer ID : ME08170091

NEW INDIA FLOATER MEDICLAIM

SCHEDULE

Insureds Details Issuing Office Details

Insured Name : Vaibhav Survase Office Code : N BLOCK,CONNAUGHT CIRCUS
(310300)
Address : A4/006 Indraraj Swami devprakash Address : BOMBAY LIFE BUILDING, N-34,
gardens CONNAUGHT CIRCUS, NEW DELHI
Near Mohan puram Sai Section
Ambarnath east ,110001
AMBERNATH ,MAHARASHTRA, 421501
Phone No/Mobile No. : 9766774411 Phone No : 23723521
E-mail/Fax : vaivasurvase@gmail.com, / E-mail/Fax : pb.support@newindia.co.in /
PAN No : BTPPS4561P S.Tax Regn. No : AAACN4165CST178
GSTIN/UIN : NA / NA GSTIN : 07AAACN4165C1ZT
: SAC : 997139 (Other non-life insurance services
excl RI)

Policy Details
Business Source Code
Policy Number : 31030034182800000161 Dev.Off : DIRECT BUSINESS (2D10673292)
level./Broker/Direct
Period of Insurance : From:25/04/2018 06:56:03 PM Agent/Bancassurance :
To:24/04/2019 11:59:59 PM
Prev. Policy no. : Phone No : NA / NA
Client Type : E-mail/Fax : / / /

Member Details
Sl. No. Name of Date of Birth Sex Occupation Relation Date of Pre-Existing Disease
Insured Person inception of
Continuous
Coverage
1 Namita 27/04/1990 F NA Spouse 25/04/2018 NA
Survase
2 Vainami 05/10/2016 F NA Children 25/04/2018 NA
Survase
3 Vaibhav 27/10/1987 M Professi Self 25/04/2018 NA
Survase onal / A
dministr
ative /
Manageri
al

Total Sum Insured 1000000

Signature Not
Details Of TPA(Notice or communication to be given in respect of claims)
Verified
Digitally signed
by Srinivasan
Vaideswaran
Date: 2018.04.25
18:59:55 IST
Policy No. : 31030034182800000161Document generated by Policy Bazaar at 25/04/2018 18:59:54 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.
(Wholly owned by the Govt. of India)

Name : HEALTH INSURANCE TPA OF INDIA Telephone : 18001023600

LIMITED
Address : MAJESTIC OMNIA BUILDING,2ND Fax : 01204765799
FLOOR, Email :
A-110, SECTOR – 4, NOIDA Toll Free No. :
NOIDA Mobile No. :

Name of Nominee : Relation :

Premium Working Table

Sl. Name of Insured Total Basic Premium Family Discount Gross Premium
No.
1 Vaibhav Survase 5695 570 5125
2 Namita Survase 5695 570 5125
3 Vainami Survase 2895 290 2605
Total Gross Premium 12855

GST 2314
Net Premium Amt. 15169
Net Premium Amt.(In words) RUPEES FIFTEEN THOUSAND
ONE HUNDRED SIXTY-NINE
ONLY

*This Policy is subject to terms and conditions of New India Floater Mediclaim.

Premium and GST Details

Rate of Tax Amount in INR
Premium `12855
SGST 0 0
CGST 0 0
IGST 18 2314

IN WITNESS WHEREOF,the undersigned being duly authorized has hereunto set his/her hand

at ______________ this _______________ day of _______________ 20

Date of Issue: 25/04/2018

(Mr Hemendra Swaroop)

[SRDivisional Manager]
Authorized Signatory For and on behalf of
The New India Assurance Company
Limited

Policy No. : 31030034182800000161Document generated by Policy Bazaar at 25/04/2018 18:59:54 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.
(Wholly owned by the Govt. of India)

Insurer Office Code : N BLOCK,CONNAUGHT CIRCUS (310300)

Address : BOMBAY LIFE BUILDING, N-34, CONNAUGHT
CIRCUS, NEW DELHI

,110001
Telephone : 23723521
Fax :

New India Floater Mediclaim

PREMIUM CERTIFICATE FOR THE PURPOSE OF DEDUCTION UNDER SECTION 80 D OF INCOME TAX ( AMENDMENT ) ACT 1986

This is to certify that Mr./Mrs. Vaibhav Survase has paid ` RUPEES FIFTEEN THOUSAND ONE HUNDRED SIXTY-NINE ONLY (in
words) towards premium for New India Floater Mediclaim for the period 25/04/2018 06:56:03 PM to 24/04/2019 11:59:59 PM

Policy no. : 31030034182800000161

Receipt no. & date : 31030081180000007920
25/04/2018

Date of Issue: 25/04/2018

(Mr Hemendra Swaroop)

[SRDivisional Manager]
Authorized Signatory For and on behalf of
The New India Assurance Company
Limited
(Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation
of the policy or any alteration in the Insurance affecting the premium)

Tax Invoice No : 3103003428000161

IRDA Registration Number: 190

Policy No. : 31030034182800000161Document generated by Policy Bazaar at 25/04/2018 18:59:54 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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