IMPORTANT

21/06/2022
To,

Mrs.VINDHYA R,
W/O SANNIK A P
THANISANDRA
SK NAGAR POST
Anagalapura,Bangalore,Karnataka -562149
Mobile : 9900205709.

Dear Customer,

Re: Health Insurance Policy - P/141141/01/2023/001936

We are extremely thankful to you for your renewal instructions and payment of premium. We enclose the renewed
policy based on our records. We would request you to kindly study the renewed policy carefully and revert to us if
there is any discrepancy to enable us to attend to the same.

Kindly note that the above request is very important and if we do not hear anything from you within 15 days, we
would presume that the policy issued by us is in order and the contract is concluded.

We would like to mention that we have incorporated the name of the intermediary as indicated by you.
We wish you good health and we look forward to serve you in the days to come.

With kind regards,

Authorised Signatory

In case of a need for hospitalization, kindly prefer our network hospital (list is available in our website) for a quick
response to your claim request.

Please select the room as per your eligibility stipulated in your policy to avoid additional payment from your
pocket towards the proportionate increase which would invariably be charged by the hospital for the higher
room category occupied.

Sum insured of this Policy is meant for utilization till its expiry. Bearing this aspect in mind, we have no doubt, you
will choose appropriate hospital, room rent and treatment charges, etc.

Should you need any assistance, our customer care will be delighted to assist you, whose toll free no. is 1800-425-
2255/1800-102-4477.

However, the ultimate decision will be that of yours only.

CN=R Margabandhu,

R Margabandhu
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b154
75488cdf3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,
OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806c
a65f89e15179f5fe50a, OU=UNDERWRITING - Chief Risk Officer,
O=STAR HEALTH AND ALLIED INSURANCE COMPANY, C=IN.
Date :Tue Jun 21 14:58:26 IST 2022

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Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No: 1800-425-5522 Toll Free No:1800-425-
2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129
 Family Health Optima Insurance Plan
SHAHLIP22030V062122
Policy No. : P/141141/01/2023/001936 Previous Policy No. : P/141141/01/2022/001865
Customer Code : AA0007104706 GSTIN : 29AAJCS4517L1ZU
Customer Name : Mrs.VINDHYA R SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 9393836 Issuing Office Code : 141141
Proposer Name : Mrs.VINDHYA R Issuing Office Name : Branch Office - Hebbal II
Address : W/O SANNIK A P Address : NO. 255, 2nd Floor, 1st Main,
THANISANDRA 1st Cross,Ganganagar,
SK NAGAR POST Bangalore - 560032
Anagalapura,Bangalore,Karnataka -562149

Tel/Mobile : ./9900205709/ Tel/Mobile : 080 - 4613 1777

E-mail id : [email protected] E-mail id : [email protected]
Proposer GSTIN : - Place of Supply : -
Proposal date : 06/06/2012 Fulfiller Code : SH5549
Date of Inception of first policy : 06-JUN-2012
Intermediary Code : BA0000039152
Renewal Year : Tenth Year
Collection Number & : 1718002090 & 21/06/2022 Name : R VEENA
Date
Premium : Rs 7525 /- Tel/Mobile : /9880676276
CGST @9% : Rs 677 /- SGST / UTGST @9% : Rs 677 /-
Total Premium : Rs 8879 /- Stamp Duty : Re 1 /- E-mail id : [email protected]

Total Premium In Words : Rupees Eight Thousand Eight Hundred Seventy Nine Only
Installment Facility Optn :No Premium Payment Frequency :Annual Installment Amount Rs. : 0

Period of insurance : From : 24/06/2022 00:00 To : Midnight of 23/06/2023

Basic Floater Sum Insured : 400000
In words : Rupees: Four Lakhs Only
Bonus: Rs. 220000 Limit of Coverage : Rs. 620000 Recharge Benefit : Rs. 100000
Scheme Description : 2ADULT
Details of Insured Persons :

Sl. Name of the Insured Gender Date of Birth Age in Relationship ID Card No Pre Existing Disease Inception Date
No. Yrs with Proposer
1 Mrs.VINDHYA R F 25/04/1993 29 SELF 2364630-2 No PED declared 06/06/2012
2 Mr.SANNIK.A.P M 15/07/1987 34 SPOUSE 9393836-1 No PED declared 14/06/2018

Nominee Details

Nominee Details for the proposer Appointee Details

Relationship Age % of Appointee Relationship

S.No. Name Age
with proposer the Name with Nominee
claim

1 Mr.SANNIK.A.P Spouse 35 100

Entered By : PREMIA For Star Health and Allied Insurance Company Ltd.
Approved By : PORTAL

L66010TN2005PLC056649 Authorised Signatory

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No: 1800-425-5522 Toll Free No:1800-425-2255 /
1800-102-4477,CIN : L66010TN2005PLC056649 Email :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129

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 Attached to and forming part of Policy No. P/141141/01/2023/001936

Sector Classification

Rural

Please check whether the details given by you about the insured persons in the proposal form are incorporated correctly in the policy schedule. If
you find any discrepancy, please inform us within 15 days from the date of receipt of the policy, failing which the details relating
to the insured person given in the policy schedule are deemed to have been accepted by you.

Warranted that in case of dishonor of premium cheque(s), the Company shall not be liable under the policy and the policy shall be void abinitio
(from inception).

THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED.
Important

In the event of hospitalization of insured person, intimation should be given to the Company immediately, however, within 24 hrs from the time of
admission.
Toll Free No : 1800 425 2255 / 1800 102 4477 Email: [email protected], Fax No: 1800 425 5522 .
"CONSOLIDATED STAMP DUTY PAID VIDE NO. CR0322003000838271 DTD 21/MAR/2022"
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Hebbal II on 21st
Day of June 2022.

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

Entered By : PREMIA For Star Health and Allied Insurance Company Ltd.
Approved By : PORTAL

Authorised Signatory

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No: 1800-425-5522 Toll Free No:1800-425-2255 /
1800-102-4477,CIN : L66010TN2005PLC056649 Email :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129

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 TAX Invoice

Invoice No. : 29C718Y23P000628 Customer ID : AA0007104706

Invoice Date : 21/06/22 Policy No : P/141141/01/2023/001936
Recipient Supplier

GSTIN : - GSTIN : 29AAJCS4517L1ZU

Proposer Name : Mrs.VINDHYA R NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Hebbal II
Address : W/O SANNIK A P Tel/Mobile : NO. 255, 2nd Floor, 1st Main,
THANISANDRA 1st Cross,Ganganagar,
SK NAGAR POST Bangalore - 560032
City : City : HEBBAL II
State : Karnataka State : Karnataka
Pincode : 562149 Pincode : 560032
Client Category : IND Place of Supply : 29 - Karnataka

HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% CESS@1% Total Invoice Value
SAC Service(s)
A B C=A-B D = C * IGST E=C F = C *UTGST G=C*Cess H=C+D+E+F+G
Code
*CGST or SGST

997133 Insurance Services 7525 0 7525 677 677 Rs. 8879

Total Invoice Value (in Figures) : Rs. 8879
Total Invoice Value (in Words) : Rupees: Eight thousand eight
hundred seventy-nine only
Amount of Tax Subject to reverse Charge : No

Important Note:

The invoice is issued as per Section 31 of the CGST Act

In case no GSTIN or incorrect GSTIN is provided by the Proposer at Proposal stage, Star Health and Allied Insurance Co Ltd shall not be
responsible for any Input Tax Credit losses and no subsequent revision of invoice will be undertaken.

E. & O.E
This is a digitally signed document and hence no physical signature is required

Corporate Identity Number L66010TN2005PLC056649 Email ID : [email protected]

Entered By : PREMIA For Star Health and Allied Insurance Company Ltd.
Approved By : PORTAL

Authorised Signatory

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No: 1800-425-5522 Toll Free No:1800-425-2255 /
1800-102-4477,CIN : L66010TN2005PLC056649 Email :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129

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