THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)
POLICY SCHEDULE CUM CERTIFICATE OF INSURANCE
Private Car Package Policy
UIN Number - IRDAN190RP0042V01100001
Policy Number :53070631250100001103
POLICY ISSUING OFFICE: BUSINESS CHANNEL/CPSC User: CLAIM CONTACT:
BELTOLA BRANCH (530706), NAME: [Link] PAUL - (1D7716096) GUWAHATI (530001)
BELTOLA BRANCH , OPP. SBI BELTOLA Mr. Kalpojit Baishya - (NIAAG00116668), ADDRESS: THE NEW INDIA ASSURANCE CO. LTD.,
BRANCH, NEAR A. G. BUS STOP , BELTOLA- PHONE NUMBER: / / 7002080368 STAR CITY TOWER,5TH FLOOR,LACHIT NAGAR
BASISTHA ROAD , LAND/FAX NUMBER:/ GUWAHATI - 781007, (ASSAM ) , , , ASSAM , 781007.
ASSAM , 781029. EMAIL:kalpojitbaishya@[Link] / PHONE NUMBER: 03612454344 /
PHONE NUMBER: NA / 7002379221 MOBILE NUMBER:
FAX NUMBER:NA / NA Email: ch53@[Link]
Email:nia.530706@[Link]
INSURED DETAILS
Insured Name NABA BAISHYA Customer ID POC4009297 (PAN No :NA)
Insured Address S/O PRABIN BAISHYA VILL-MIRZA NEARD K COLLEGE Contact Number / /
AZARA,GUWAHATI KAMRUP ASSAM,,
MIRZA ,ASSAM, 781125
Email
GSTIN NA
POLICY DETAILS
Period of cover 02/07/2025 [Link] PM to 01/07/2026 [Link] PM Receipt Number 10000089250700075765 -
02/07/25
Previous Insurer Not available Previous Policy Number VALUATION REPORT
VEHICLE DETAILS
Registration Number AS-01-BR-4856 Chassis no./Engine Number MA1TA2SJXF2B20915/SJF4
B24246
Make / Model MAHINDRA &/SCORPIO Variant: SCORPIO S10
Year of manufacture 2015 Type of body / Type of Fuel SUV/Diesel
Colour A WHITE Cubic capacity(cc) 2179cc
/Wattage(kW):
Seating capacity including 7 Name of registration Guwahati - AS 01
Driver authority
Geographical Area / Zone India Name of the Financier
Cover Note No/Cover Note / Automobile Association none
Issue Date: membership
FASTag ID:
INSURED DECLARED VALUE (in Rs)
Vehicle Trailer Non-Elec Acc Electrical Acc Bi-fuel/CNG/LPG kit Total Value
600000 0 0 0 600000
SCHEDULE OF PREMIUM
Own Damage Liability
Basic OD Premium 2588 Basic TP Premium 7897
(+)Legal Liability Premium for Other Employees 50
for(Other than IMT 28) 1 person(IMT - 29)
Calculated OD Premium 2588 Calculated TP Premium 7947
Total OD Premium 2588 Total TP Premium 7947
Net Premium in Rs 10,535
GST in Rs 1,896
Signature Not
Verified
Digitally signed
by DHIRAJ Policy No. : 53070631250100001103Document generated by AG_0159858 at 2025/07/02 [Link].
KUMAR
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Date: 2025.07.02
[Link] IST Give your valuable feedback on [Link]
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 [Link] 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 [Link]
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THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)
Total Payable in Rs 12,431
Total Payable in Rs(in words): RUPEES TWELVE THOUSAND FOUR HUNDRED THIRTY-ONE ONLY
GSTIN(Issuing Office) 18AAACN4165C2ZP
SAC 997134 (Motor vehicle insurance services)
Limitation as to use:The Policy covers use of the vehicle for any purpose other than: a)Hire or Reward b)Carriage of goods (other than
samples or personal luggage) c)Organized racing d)Pace making e)Speed testing f) Reliability Trials g)Any purpose in connection with Motor
Trade
Limits of Liability:Limit of the amount the Company's Liability Under Section II 1(i) in respect of any one accident: as per the Motor Vehicles
Act, 1988. Limit of the amount of the Company's Liability Under Section II 1(ii) in respect of any one claim or series of claims arising out of
one event: Up to Rs. 7,50,000
For individual covers (OD) in RS:600000 Compulsory excess in Rs:2000
Imposed excess in Rs:0 Voluntary excess in Rs:0
Persons or classes of persons entitled to drive:Any person including the insured provided that a person driving holds an effective driving
license at the time of the accident and is not disqualified from holding or obtaining such a license. Provided also that the person holding an
effective Learner's License may also drive the vehicle and that such a person satisfies the requirement of Rule 3 of the Central Motor Vehicles
Rules, 1989.
PA cover for Owner Driver
Name of Nominee Age of Nominee Relationship with the Name of the Appointee (if Relationship to the
Insured Nominee is a minor) Nominee
none 0 none none none
PA cover for named persons
Name CSI Opted(Rs.) Nominee Relationship
none 0 NA NA
Premium and GST Details
Rate of Tax Amount in INR
Premium Rs 10,535
SGST 9 948
CGST 9 948
IGST 0 0
In witness where of this policy has been signed at BELTOLA BRANCH on this 02-JUL-25WARRANTED THAT IN CASE OF DISHONOUR OF THE
PREMIUM CHEQUE, THIS DOCUMENT STANDS AUTOMATICALLY CANCELLED ABINITIO This policy is subject to the Terms, conditions and
exceptions applicable to Package policy attached/available on the web site [Link] IMT Endorsement Number(s) printed
herewith attached 22,29.
Important notice:
The insured is not indemnified, if, the vehicle is used or driven otherwise than in accordance with this schedule. Any payment made by the
company by reason of wider terms appearing in the certificate in order to comply with the Motor Vehicles Act, 1988 is recoverable from the
insured: see clause headed "AVOIDANCE OF CERTAIN TERMS AND RIGHTS OF RECOVERY". It is clarified that in case the declaration regarding
the ncb or other previous policy details made by the insured, is found to be incorrect, all the benefits (including claim) under section-1 of this
policy, will stand forfeited.
Anti Money Laundering Clause: In the event of a claim under the policy exceeding Rs 1lakh or a claim for refund of premium exceeding Rs 1
lakh, the insured will comply with the provisions of AML policy of the company. The AML policy is available in all our operating offices as well
as Company website.
I/We hereby certify that the policy to which this Certificate relates For and on behalf of The New India Assurance Company Limited
as well as this Certificate of Insurance are issued in accordance
with the provisions of Chapter X and XI of M.V. Act, 1988.
Date of Issue: 02/07/2025
Policy No. : 53070631250100001103Document generated by AG_0159858 at 2025/07/02 [Link].
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on [Link]
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 [Link] 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 [Link]
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THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)
(Mr. JANGMINLIEN LHUNGDIM)
[SR BRANCH MANAGER]
Duly Constituted Attorney(s)
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 : 53070625P0001830
IRDA Registration Number: 190
NIA PAN NUMBER: AAACN4165C
Policy No. : 53070631250100001103Document generated by AG_0159858 at 2025/07/02 [Link].
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on [Link]
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 [Link] 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 [Link]
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Page 3 of 3
