IMPORTANT

26/10/2020
To,

N.ILANGOVAN,
50-51, EAST VELI STREET,
MADURAI

Madurai (M Corp.),Madurai,Tamil Nadu -625001

Mobile : 9843150331.

Dear Customer,

Re: Health Insurance Policy - P/121319/01/2021/003300

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 :Mon Oct 26 09:35:44 IST 2020

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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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Family Health Optima Insurance Plan
SHAHLIP21211V042021

In consideration of payment of Rs.15812 /- towards renewal premium of Policy number: P/121319/01/2020/002011, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No : P/121319/01/2021/003300

GSTIN : 33AAJCS4517L1Z5
Customer Code : AA0000601412
Customer Name : N.ILANGOVAN SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 310053 Issuing Office Code : 121319
Proposer Name : N.ILANGOVAN Issuing Office Name : Branch Office - Anna Nagar
Address : 50-51, EAST VELI STREET, Address : No. 5 & 6, Aringar Annanagar,
MADURAI 2nd East Main Street,
Opp. to Ambiga Women's College,
Madurai (M Corp.),Madurai,Tamil
Nadu-625001
Tel/Mobile : -/9843150331/ Tel/Mobile : 0452-4354555
E-mail id : pioneeritech@gmail.com E-mail id : madurai.annanagar@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 11/09/2007 Fulfiller Code : SH4635
Date of Inception of first policy : 11-SEP-2007
Intermediary Code : SMD
Renewal Year : Thirteenth Year
Collection Number & : 1413003327 & 26/10/2020 Name : L.VENKATESH
Date
Premium : Rs 13400 /- Tel/Mobile : /9080050800
CGST @9% : Rs 1,206 /- SGST / UTGST @9% : Rs 1,206 /-
E-mail id :
Total Premium : Rs 15812 /- Stamp Duty : Re 1 /-

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

Period of insurance : From : 31/10/2020 00:00 To : Midnight of 30/10/2021

Basic Floater Sum Insured : 300000 Scheme Description : 2A+2C
In words : Rupees: Three Lakhs Only
Bonus: Rs. 225000 Limit of Coverage : Rs. 525000 Recharge Benefit : Rs. 75000
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 N.ILANGOVAN M 28/03/1973 47 SELF 310053-5 No PED declared 11/09/2007
2 I.GAYATHIRI F 22/02/1977 43 SPOUSE 310053-6 No PED declared 11/09/2007
3 I.ELAKKIYA F 29/01/2001 19 DEPENDANT 310053-7 No PED declared 11/09/2007
CHILD
4 I.KAVIYA F 15/06/2004 16 DEPENDANT 310053-8 No PED declared 11/09/2007
CHILD

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

IRDAI Regn. No 129

Corporate Identity Number U66010TN2005PLC056649 Authorised Signatory
Email ID : support@starhealth.in

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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 Attached to and forming part of Policy No. P/121319/01/2021/003300
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 I. GAYATHIRI Spouse 43 100

Sector Classification

Urban

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).

Condition No. 3 regarding delay in payment of claim shall read as follows and not as stated in policy wordings:
"The Company shall pay interest as per Insurance Regulatory and Development Authority of India (Protection of Policyholders' Interests)
Regulations, 2017, in case of delay in payment of an admitted claim under the Policy"
Condition No: 13 of the policy wordings should read as follows
"Automatic Termination: The insurance under this policy shall terminate immediately on the earlier of the following events:
* Upon the death of the Insured Person This means that, the cover for the surviving members of the family will continue, subject to other terms of
the policy.
* Upon exhaustion of the Basic Sum Insured, Basic Sum Insured plus Bonus, Basic Sum Insured plus Bonus plus Restore and / or Recharge
Sum Insured."
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: support@starhealth.in, Fax No: 1800 425 5522 .
"CONSOLIDATED STAMP DUTY PAID VIDE G.O.(RT) NO.218 DATED.07th July 2020"
AYUSH Hospital means a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions are carried out by
AYUSH Medical Practitioner(s) comprising of any of the following:
1. Central or State Government AYUSH Hospital or
2. Teaching hospital attached to AYUSH College recognized by the Central Government / Central Council of Indian
Medicine/Central Council for Homeopathy; or
3. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized system of medicine,
registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH
Medical Practitioner and must comply with all the following criterion:
i. Having at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where
surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the insurance Company's
authorized representative.

AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic,
Polyclinic or any such health centre which is registered with the local authorities, wherever applicable and having facilities for carrying out
treatment procedures and medical or surgical/para-surgical interventions or both under the supervision of registered AYUSH Medical
Practitioner (s) on day care basis without in-patient services and must comply with all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures
are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the insurance company's authorized representative.

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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 Attached to and forming part of Policy No. P/121319/01/2021/003300

It is hereby made clear that all terms, conditions, clauses, warranties, exclusions etc., as already issued, forming part of the policy of
insurance originally issued at the time of inception of this relationship, shall continue to be operative and unaltered, forming part of this
renewal insurance cover also.

Reference may be made to those terms, conditions etc., for identifying the scope/extent of coverage.

Other excluded expenses as detailed in our website "www.starhealth.in"

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Anna Nagar on 26th
Day of October 2020.

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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 Hospitalisation Benefit Policy
Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986

Policy No : P/121319/01/2021/003300 Type Of Policy : Family Health Optima Insurance - 2017

Issue Office : 121319 - Branch Office - Anna Nagar

Address : No. 5 & 6, Aringar Annanagar,

2nd East Main Street,
Opp. to Ambiga Women's College,
Toll Free No : 0452-4354555
Email : madurai.annanagar@starhealth.in

This is to certify that N.ILANGOVAN has paid Rs 15812 (Total Premium In Words : Indian Rupees Fifteen Thousand Eight
Hundred Twelve Only ) towards Premium for Hospitalization Insurance vide Policy No: P/121319/01/2021/003300 for the
Period 31-OCT-20 To 30-OCT-21 issued on 26-OCT-20 .
Payment received by Cheque/Credit/Debit Card vide collection No:1413003327

Note :- This Certificate must be surrendred 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.

For Star Health and Allied Insurance Company Ltd.

Authorised Signatory

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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 TAX Invoice

Invoice No. : 33G413Y21P000339 Customer ID : AA0000601412

Invoice Date : 26/10/20 Policy No : P/121319/01/2021/003300
Recipient Supplier

GSTIN : - GSTIN : 33AAJCS4517L1Z5

Proposer Name : N.ILANGOVAN NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Anna Nagar
Address : 50-51, EAST VELI STREET, Tel/Mobile : No. 5 & 6, Aringar Annanagar,
MADURAI 2nd East Main Street,
Opp. to Ambiga Women's College,
City : Madurai (M Corp.),Madurai,Tamil City : ANNA NAGAR
Nadu-625001
State : Tamil Nadu State : Tamil Nadu
Pincode : 625001 Pincode : 625020
Client Category : IND Place of Supply : 33 - Tamil Nadu

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 13400 0 13400 1206 1206 Rs. 15812

Total Invoice Value (in Figures) : Rs. 15812
Total Invoice Value (in Words) : Rupees: Fifteen thousand eight
hundred twelve 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

IRDAI Regn. No 129 Corporate Identity Number U66010TN2005PLC056649 Email ID : stargst@starhealth.in

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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