IMPORTANT

12/03/2023
To,

ANIL KUMAR,
S/O SH. SHOCHAND
NEAR VARDAN PUBLIC SCHOOL , PATTI - KUTWAL
TEH. - MANESAR , DISTT. - GURGAON
Baghanki(4),Gurgaon,Haryana -122105
Mobile : 9911553937.

Dear Customer,

Re: Health Insurance Policy - P/161117/01/2023/020903

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 :Sun Mar 12 16:50:39 IST 2023

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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 :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Family Health Optima Insurance Plan
SHAHLIP22030V062122

In consideration of payment of Rs.24149 /- towards renewal premium of Policy number: P/161117/01/2022/019039, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No : P/161117/01/2023/020903

GSTIN : 06AAJCS4517L1Z2
Customer Code : AA0006745722
Customer Name : ANIL KUMAR SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 8957951 Issuing Office Code : 161117
Proposer Name : ANIL KUMAR Issuing Office Name : Branch Office - Gurgaon
Address : S/O SH. SHOCHAND Address : 412/2, K - I Tower,
NEAR VARDAN PUBLIC SCHOOL , M G Road, Sector 14,
PATTI - KUTWAL Gurgaon, Haryana
TEH. - MANESAR , DISTT. -
GURGAON
Baghanki(4),Gurgaon,Haryana -122105
Tel/Mobile : NIL/9911553937/NIL Tel/Mobile : 0124-4255201 & 4797454
E-mail id : shakshiyadav12596@gmail.com E-mail id : gurgaon@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 21/03/2018 Fulfiller Code : SH7972
Date of Inception of first policy : 30-MAR-2018
Intermediary Code : BA0000081179
Renewal Year : Fifth Year
Collection Number & : 1134022741 & 12/03/2023 Name : Mr.JITENDER
Date
Basic Cover : Rs 20465 /- Tel/Mobile : 9582880036/9718536718
Section 1(Extra Protect Add-on Cover) : Rs /-
Section 2(Extra Protect Add -on Cover) : Rs 0 /- : jitender81179@gmail.com
E-mail id
Premium : Rs 20465 /-
CGST @9% : Rs 1,842 /- SGST / UTGST @9% : Rs 1,842 /-
Total Premium : Rs 24149 /- Stamp Duty : Re 1 /-
Total Premium In Words : Rupees Twenty Four Thousand One Hundred Forty Nine Only
Installment Facility Optn :No Premium Payment Frequency :Annual Installment Amount Rs. : 0

Period of insurance : From : 30/03/2023 00:00 To : Midnight of 29/03/2024

Basic Floater Sum Insured : 500000
In words : Rupees: Five Lakhs Only
Bonus: Rs. 225000 Limit of Coverage : Rs. 725000 Recharge Benefit : Rs. 150000
Scheme Description : 2ADULT+1CHILD
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 ANIL KUMAR M 20/03/1972 51 SELF 8957951-1 No PED declared 30/03/2013
2 NEELAM F 09/03/1978 45 SPOUSE 8957951-2 No PED declared 30/03/2013
3 KUNAL M 21/07/1998 24 DEPENDANT 8957951-4 No PED declared 30/03/2013
CHILD

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

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 Attached to and forming part of Policy No. P/161117/01/2023/020903
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 Neelam Spouse 44 100

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).

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 .

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 - Gurgaon on 12th
Day of March 2023.

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

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 TAX Invoice

Invoice No. : 6L134Y23P0000836 Customer ID : AA0006745722

Invoice Date : 12/03/23 Policy No : P/161117/01/2023/020903
Recipient Supplier

GSTIN : - GSTIN : 06AAJCS4517L1Z2

Proposer Name : ANIL KUMAR NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Gurgaon
Address : S/O SH. SHOCHAND Tel/Mobile : 412/2, K - I Tower,
NEAR VARDAN PUBLIC SCHOOL , M G Road, Sector 14,
PATTI - KUTWAL Gurgaon, Haryana
TEH. - MANESAR , DISTT. -
GURGAON
City : City : GURGAON
State : Haryana State : Haryana
Pincode : 122105 Pincode : 122001
Client Category : IND Place of Supply : 6 - Haryana

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 20465 0 20465 1842 1842 Rs. 24149

Total Invoice Value (in Figures) : Rs. 24149
Total Invoice Value (in Words) : Rupees: Twenty-four thousand one
hundred forty-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.

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

Corporate Identity Number L66010TN2005PLC056649 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 : L66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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