THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

ADDITIONAL ENDORSEMENT DOCUMENT

Personal Accident
Insured Name : ICS INDIA PRIVATE LTD. Insurer Office Code : DADAR D.O.I (142100)
Address : SHOP NO 17 AND 18, Address : B RATAN CENTRAL, 1ST
OMKAR INDUSTRIAL, PLOT FLOOR, PLOT CS 777/778,
NO 139, SEC 7, BHOSARI, DR. BABASAHEB
PUNE AMBEDKAR ROAD, PAREL
(E) MUMBAI-400012,

PUNE ,MAHARASHTRA, ,400012

411026
Telephone : //XXXXXX1076 Telephone : 2224135543 / 2224154961 /
2224135543
Fax : Fax :
Email : [email protected] Email : [email protected]
Insured Pan Number : AADCI4184R
GSTIN : 27AADCI4184R1ZV GSTIN : 27AAACN4165C3ZP
UIN : NA SAC : 997133 (Accident and health
insurance services)

Endorsement attached to forming part of Policy Number : 14210042240100000207

Department : Personal Accident Cover : Standard CoverPolicy
Period of Insurance : From 29/05/2024 04:38:20 PM To Endorsement No : 14210042240183000021
28/05/2025 11:59:59 PM
Effective Date : 03 December 2024
Date Signed : 03-DEC-24 Sum Insured` : 93,950,000.00
Additional Premium ` : 570.00 Additional S.T/GST. ` : 102
Refund Premium ` : N/A Refund S.T/GST ` : N/A
Policy Duration :

Number of Member Risk Added : 0

Number of Member Risk Deleted : 0

It is hereby understood and agreed that the endorsement on policy 14210042240100000207 will be in effect
from 03 December 2024.
Reason IT IS HEREBY AGREED & DECLARED TO ADD 2 MEMBERS NAMED BHASKAR POORNA ( AGE-28 YRS,
SALARY - 23000/- PM) & MANASANI AKHIL REDDY (AGE-29 YRS, SALARY - 22000) W.E.F. 03/12/2024.
IN VIEW OF THE ABOVE RS. 672/- INCLUDING GST IS HEREBY CHARGED TO THE INSURED. ALL
OTHER T & C WILL REMAIN UNALTERED.

Premium and GST Details

Rate of Tax Amount in INR
Premium ` 570.00
SGST 9 51
CGST 9 51
IGST 0 0
TOTAL PAYABLE : 672
TOTAL PAYABLE (In words) : RUPEES SIX HUNDRED SEVENTY-TWO ONLY

IN WITNESS WHEREOF THIS POLICY has been signed at _______________ this 03-DEC-24.

Place : ,
,400012
Date :03-DEC-24

Signature Not
Verified
Digitally signed
by DHIRAJ Policy No. : 14210042240100000207Document generated by 41389 at 03/12/2024 16:58:21 Hours.
KUMAR Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Date: 2024.12.03
For redressal
16:58:30 IST 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.

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THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

For and on behalf of

The New India Assurance Company Limited

Authorized Signatory

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 : 14210024E0013969

IRDA Registration Number: 190

NIA PAN NUMBER: AAACN4165C

Policy No. : 14210042240100000207Document generated by 41389 at 03/12/2024 16:58:21 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.

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