IMPORTANT

To, 17-MAR-22

ARJIT SINGHA
197 G, Rajpur Road Telpehone Exchange Lane
Rajpur Road , Dehradun
DEHRADUN
Dehradun,Dehradun,Uttarakhand -248009
Mobile : 9643633540.

Dear Customer,

Re: Health Insurance Policy - P/161300/01/2022/003235

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
"Let Star Health help you to become healthier and happier. Star Wellness Benefits includes Mind Body healing and other
Condition management programmes (Weight management, Diabetes etc....) Visit www.starhealth.in / customer portal login and
start your journey with us to Better Health".

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 :Thu Mar 17 13:43:10 IST 2022

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 :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129
 YOUNG STAR INSURANCE POLICY
SCHEDULE (Floater)
UNIQUE ID:SHAHLIP22036V042122

In consideration of payment of Rs.9375/- towards renewal premium of Policy number: P/161300/01/2021/002741, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No : P/161300/01/2022/003235

Customer Code : AA0024549939 GSTIN : 05AAJCS4517L1Z4
Customer Name : ARJIT SINGHA SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 27893849 Issuing Office Code : 161300
Proposer's Name : ARJIT SINGHA Issuing Office Name : Area Office - Dehradun
Address : 197 G, Rajpur Road Telpehone Address : 2nd Floor, NCR Plaza, New Cant
Exchange Lane Road,
Rajpur Road , Dehradun Ravindranath Tagore Marg,
DEHRADUN Dehradun-248001 (Uttarakhand )
Dehradun,Dehradun,Uttarakhand-
248009
Phone No : 0/9643633540/ Phone No : 0135- 2749603, 2749604
E-mail Id : [email protected] E-mail Id : [email protected]
Proposer GSTIN : - Place of Supply : -
Proposal date : 13/03/2021 Fulfiller Code : SH41958

Date of Inception of first policy : 18-MAR-2021 Intermediary Code : BA0000517591

Renewal Year : First Year
Collection Number : 1240005936 Name : Mr.IMRAN ALI
Receipt Date : 16/03/2022
Premium :Rs 7,945 /-
CGST @9% : 715 /- SGST / UTGST @9% : 715 /- Phone No : 9719401199/9719401199
Stamp Duty :Rs 1 /- Total Premium :Rs 9,375 /-
E-mail Id : [email protected]
Total Premium In Words : Rupees Nine Thousand Three Hundred Seventy Five Only Installment Facility Optn :No

Premium Payment Frequency :Annual Installment Amount Rs. : 0

Period of Insurance : FROM 18/03/2022 00:00 TO : Midnight Of 17/03/2023 Term : 1 Year

Scheme Description (Family Size) : 2 ADULTS Basic Floater Sum Insured : Rs. 500000 /-
Bonus : Rs. 0 /-
Total Sum Insured In Words : Rupees Five Lakhs Only Plan Type : SILVER

Entered by : SH57006 For Star Health and Allied Insurance Company Ltd.
Approved by : SH57006

IRDAI Regn. No 129

Authorised Signatory
Corporate Identity Number U66010TN2005PLC056649
Email ID : [email protected]
2 of 4

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 :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129
Attached to and forming part of Policy No : P/161300/01/2022/003235
Details of Insured Persons :
Sl. Name of the Insured Sex Date of Birth Age in Relationship with ID Card No Pre Existing Disease Inception Date
no. Yrs Proposer
1 ARJIT SINGHA M 14/04/1988 33 SELF 20772930-1 18/03/2021
Pre Existing Disease :
No Pre Existing Disease Declared
2 ARCHANA SINGHA F 20/12/1993 28 SPOUSE 27893849-1 No PED 18/03/2022
declared
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.
Sector Classification :

Urban

Toll Free No: 1800 425 2255/1800 102 4477 Email: [email protected], Fax No: 1800 425 5522

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 SEEMA SINGHA Mother 56 100

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 authorised by and on behalf of the company has set his hand at Area Office - Dehradun on 17th
Day of March 2022.

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

Entered by : SH57006 For Star Health and Allied Insurance Company Ltd.
Approved by : SH57006

Authorised Signatory

3 of 4

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 :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129
 TAX Invoice

Invoice No. : 5L240Y22P0000268 Customer ID : AA0024549939

Invoice Date : 17/03/22 Policy No : P/161300/01/2022/003235
Recipient Supplier

GSTIN : - GSTIN : 05AAJCS4517L1Z4

Proposer's : ARJIT SINGHA NAME : Star Health and Allied Insurance Co Ltd
Name - Area Office - Dehradun
Address : 197 G, Rajpur Road Telpehone Address : 2nd Floor, NCR Plaza, New Cant
Exchange Lane Road,
Rajpur Road , Dehradun Ravindranath Tagore Marg,
DEHRADUN Dehradun-248001 (Uttarakhand )

City : Dehradun,Dehradun,Uttarakhand- City : DEHRADUN

248009
State : Uttarakhand State : Uttarakhand
Pincode : 248009 Pincode : 248001
Client Category : IND Place of Supply : 5 - Uttarakhand

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

997133 Insurance 7945 0 7945 715 715 Rs. 9375

Services
Total Invoice Value (in Figures) : Rs. 9375
Total Invoice Value (in Words) : Rupees: Nine thousand three
hundred seventy-five 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 : [email protected]

Entered by : SH57006 For Star Health and Allied Insurance Company Ltd.
Approved by : SH57006

Authorised Signatory

4 of 4

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 :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129