IMPORTANT

21/05/2021
To,

MR. VIKAS CHANDRA RAI,

A-1202, Tower A, Samridhi Grand Avenue
Plot No. GH09D, Techzone 4, Greater Noida, Uttar Pradesh

Bisrakh Jalalpur,Gautam Buddha Nagar,Uttar Pradesh -201301

Mobile : 9990792400.

Dear Customer,

Re: Health Insurance Policy - P/161118/01/2022/006726

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 :Fri May 21 11:37:12 IST 2021

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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
SHAHLIP21011V052122
Policy No. : P/161118/01/2022/006726 Previous Policy No. : P/161118/01/2021/001779
Customer Code : AA0001748975 GSTIN : 07AAJCS4517L1Z0
Customer Name : MR. VIKAS CHANDRA RAI SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 2344746 Issuing Office Code : 161118
Proposer Name : MR. VIKAS CHANDRA RAI Issuing Office Name : Branch Office - Janak Puri
Address : A-1202, Tower A, Samridhi Grand Address : C-2, Third Floor, New Krishna Park
Avenue Vikas Puri, Near Janakpuri West Metro Station
Plot No. GH09D, Techzone 4, Janakpuri
Greater Noida, Uttar Pradesh

Bisrakh Jalalpur,Gautam Buddha

Nagar,Uttar Pradesh-201301
Tel/Mobile : /9990792400/ Tel/Mobile : 011 - 46763300 - 14
E-mail id : vikascrai@gmail.com E-mail id : janakpuri@starhealth.in
Proposer GSTIN : - Place of Supply : Haryana / State Code : 6
Proposal date : 22/05/2012 Fulfiller Code : SH6097
Date of Inception of first policy : 22-MAY-2012
Intermediary Code : SMD
Renewal Year : Ninth Year
Collection Number & : 1172006797 & 21/05/2021 Name : AJAY KUMAR GAUR
Date
Premium : Rs 12705 /- Tel/Mobile : NIL
IGST @18% : Rs 2,287 /-
Total Premium : Rs 14992 /- Stamp Duty : Re 1 /- E-mail id :

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

Period of insurance : From : 24/05/2021 00:00 To : Midnight of 23/05/2022

Basic Floater Sum Insured : 300000
In words : Rupees: Three Lakhs Only
Bonus: Rs. 195000 Limit of Coverage : Rs. 495000 Recharge Benefit : Rs. 75000
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 MR. VIKAS CHANDRA M 19/10/1979 41 SELF 2344746-1 No PED declared 22/05/2012
RAI
2 MRS. RACHNA RAI F 28/10/1979 41 SPOUSE 2344746-2 No PED declared 22/05/2012
3 MASTER VISHESH RAI M 05/07/2008 12 DEPENDANT 2344746-3 No PED declared 22/05/2012
CHILD

Entered By : PORTAL 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/161118/01/2022/006726
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 Rachna Rai Spouse 41 100

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).

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: support@starhealth.in, Fax No: 1800 425 5522 .
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Janak Puri on 21st
Day of May 2021.

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

Entered By : PORTAL 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. : 7B172Y22P0002998 Customer ID : AA0001748975

Invoice Date : 21/05/21 Policy No : P/161118/01/2022/006726
Recipient Supplier

GSTIN : - GSTIN : 07AAJCS4517L1Z0

Proposer Name : MR. VIKAS CHANDRA RAI NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Janak Puri
Address : A-1202, Tower A, Samridhi Grand Tel/Mobile : C-2, Third Floor, New Krishna Park
Avenue Vikas Puri, Near Janakpuri West Metro
Plot No. GH09D, Techzone 4, Station
Greater Noida, Uttar Pradesh Janakpuri

City : Bisrakh Jalalpur,Gautam Buddha City : JANAK PURI

Nagar,Uttar Pradesh-201301
State : Uttar Pradesh State : Delhi
Pincode : 201301 Pincode : 110018
Client Category : IND Place of Supply : 7 - Delhi

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 12705 0 12705 2287 Rs. 14992

Total Invoice Value (in Figures) : Rs. 14992
Total Invoice Value (in Words) : Rupees: Fourteen thousand nine
hundred ninety-two 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 U66010TN2005PLC056649 Email ID : stargst@starhealth.in

Entered By : PORTAL 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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