Star Health And Allied Insurance Company Limited

Date : 23-Apr-2024
To, IMPORTANT

MR.ANIL SINGH PANWAR ,

M/S DWARIKESH SUGAR INDUSTRIES LTD.
DWARIKESH PURAM
AFZALGARH,DISTT-BIJNOR
Dhampur Tehsil,Uttar Pradesh-246722
Mobile : 94XXXXXX75

Dear Customer,

Re: Health Insurance Policy - 11250865496810

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.

Page 1 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@starhealth.in Website :www.starhealth.in
IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Family Health Optima Insurance Plan

Unique Identification No. SHAHLIP23164V072223

In Consideration of payment of Rs. 28,517/- towards renewal premium of policy

number:P/161311/01/2024/000434, the policy stands renewed for a further period of 1 Year as per
the details given below
Renewal Endorsement No:11250865496810
Customer Code : 9190782 GSTIN : 05AAJCS4517L1Z4
Customer Name : MR.ANIL SINGH PANWAR SAC Code : 997133 / Accident and Health
Insurance Services
Cust CKYC No : -
Proposer Code : 9190782 Issuing Office Code : 161311
Proposer Name : MR.ANIL SINGH PANWAR Issuing Office Name : Branch Office - Haridwar
Proposer Address : M/S DWARIKESH SUGAR Issuing Office Address : 2ND FLOOR,KUMAR TOWER,
INDUSTRIES LTD. RANIPUR MORE,HARIDWAR
DWARIKESH PURAM .
AFZALGARH,DISTT-BIJNOR Haridwar Tehsil Uttarakhand
Dhampur Tehsil Uttar Pradesh 249407
246722
Phone No : 94XXXXXX75 Phone No : 0133-4220202
E-mail Id : anXXXXXXXX.XX@dwarikesh.com E-mail Id : Haridhwar@starhealth.in
Proposer GSTIN : NO Place of Supply : Uttarakhand
Proposal date : 24-Apr-2018 Fulfiller Code : SH39175
Date of Inception : 09-May-2014
of first policy
Renewal Year : Tenth Year Intermediary : BA0000358250
Collection No : 161311/RV/2025/0123463191
Code
Collection Date : 23-Apr-2024

Premium : Rs. 24,167/-

Name : MR.BHUWAN
CHANDRA PATHAK
IGST @ 18% : Rs. 4,350/-
Phone No :9917162803/991716280
3
E-mail Id : bhuwanch.pathak@gm
ail.com
Total Premium : Rs. 28,517/-
Stamp Duty : Re. 1/-

Total Premium In Words : Rupees Twenty Eight thousand five hundred

seventeen only
PERIOD OF INSURANCE : From : 09-May-2024 00:00 To : Midnight Of 08-May-2025 Policy Term :1 Year
Installment Facility Option:No Premium Payment Frequency :Annual Installment Amount Rs. : 0/-
Scheme Description (Family Size) :2A+1C Basic Floater Sum Insured :Rs. 5,00,000/-
Bonus : Rs. 5,00,000/- Limit of Coverage : Rs. 10,00,000/- Recharge Benefit : Rs. 1,50,000/-

Entered by : CUSTPORTAL For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL
IRDAI Regn.No.129

Corporate Identity Number L66010TN2005PLC056649

Authorised Signatory Page 2 of 5
Email ID: info@starhealth.in

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@starhealth.in Website :www.starhealth.in
IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Attached to and forming part of Policy No: 11250865496810

Details of Insured Persons :
Sl. Age in Relationship Inception
Name of the Insured Gender Date of Birth ID Card No
no. Yrs with Proposer date
ANIL SINGH PANWAR
1 Male 07-Mar-1969 55 Self 9190782-1 09-May-2014

Pre Existing Disease : No PED Declared

KAJAL SINGH
2 Female 05-Jul-1970 53 Spouse 9190782-2 09-May-2014

Pre Existing Disease : No PED Declared

ABHIJEET
3 Male 15-Jul-2001 22 Son 9190782-4 09-May-2014

Pre Existing Disease : No PED Declared

Nominee Details:
Nominee Details for the Proposer Appointee Details
S.No Name Relationship Age % of the Appointee Name Appointee Relationship
with proposer claim Age with nominee

1 KAJAL SINGH Spouse 53 100

Sector Classification:
Urban Informal Sector

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 - Haridwar on 23rd Day of April 2024.
As per Section 34 of CGST Act of 2017, Policy Issued in one Financial Year and Cancelled in another Financial Year
on or after 01st of December, then Only Premium Amount will be Refunded to the Customer and GST Amount will
Not be Refunded. Customer has to Claim the Refund of GST Amount from the GST Portal.

Entered by : CUSTPORTAL For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL

Authorised Signatory Page 3 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@starhealth.in Website :www.starhealth.in
IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Hospitalisation Benefit Policy

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

Policy No : 11250865496810 Type of Policy : Family Health Optima Insurance

- 2022
Issue Office : 161311-Branch Office - Haridwar

Address : 2ND FLOOR,KUMAR TOWER,

RANIPUR MORE,HARIDWAR
.
Haridwar Tehsil Uttarakhand 249407

Tel / Fax : 0133-4220202

Email : Haridhwar@starhealth.in

This is to certify that MR.ANIL SINGH PANWAR has paid Rs 28,517/- (Total Premium : Indian Rupees
Twenty Eight thousand five hundred seventeen only ) towards Premium for Hospitalization Insurance vide
Policy No: 11250865496810 for the Period 09-May-2024 To 08-May-2025 issued on 23-Apr-2024.

Payment received by Payment Gateway vide Receipt No: 161311/RV/2025/0123463191/1 Receipt

Date: 23-Apr-2024

Note :- This Certificate must be surrendered 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.

Date : 23-Apr-2024 For and on behalf of

Place : Branch Office - Haridwar Star Health and Allied Insurance Company Ltd.

IRDA Regn.No.129

Corporate Identity Number L66010TN2005PLC056649 Authorised Signatory

Email ID: info@starhealth.in

Entered by : CUSTPORTAL For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL

Authorised Signatory Page 4 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@starhealth.in Website :www.starhealth.in
IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Tax Invoice
Invoice No. : 052404I000258743 Customer ID : 9190782
Invoice Date : 23-Apr-2024 Policy No. : 11250865496810
Recipient Supplier
GSTIN : GSTIN : 05AAJCS4517L1Z4
Name : MR.ANIL SINGH PANWAR Name : Star Health and Allied Insurance Co Ltd -
Branch Office - Haridwar
Address : M/S DWARIKESH SUGAR INDUSTRIES Address : 2ND FLOOR,KUMAR TOWER,
LTD.
DWARIKESH PURAM RANIPUR MORE,HARIDWAR
AFZALGARH,DISTT-BIJNOR .
City : Dhampur Tehsil Pin Code : 246722 City : Haridwar Tehsil Pin Code : 249407

State : Uttar Pradesh Client : IND State : Uttarakhand Place of : Uttarakhand

Category supply

Taxable IGST @ UT/SGST @ CESS @ Total Invoice

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

Insurance
997133 24,167.00 0 24,167.00 4,350.00 0 0 0 28,517.00
Services

Total Invoice Value (in Figures) : Rs. 28,517/-

Total Invoice Value (in Words) : Rupees Twenty Eight thousand five hundred seventeen 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

IRDAI Regn.No.129 Corporate Identity Number L66010TN2005PLC056649 Email ID: stargst@starhealth.in

Entered by : CUSTPORTAL For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL

Authorised Signatory Page 5 of 5

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