IMPORTANT

To, 09/12/2020

SUDEB MONDAL,
C/O - MADHUSUDAN MONDAL ( NITYANANDA SARANI, P.O - BAMANGACHI, P.O
- BARASAT - 743248
.
.
Chandrapur (CT),North Twenty Four Parganas,West Bengal -743248
Mobile : 8276820306.

Dear Customer,

Re: Health Insurance Policy - P/191111/01/2021/016228

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 :Wed Dec 09 18:53:00 IST 2020

1 of 5

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
 MEDICLASSIC INSURANCE POLICY (INDIVIDUAL)
SCHEDULE
Unique Identification No. SHAHLIP21215V052021

In consideration of payment of Rs.4335/- towards renewal premium of Policy number: P/191111/01/2020/012079, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No : P/191111/01/2021/016228

Customer Code : AA0004233402 GSTIN : 19AAJCS4517L1ZV
Customer Name : Mr.SUDEB MONDAL SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 6122635 Issuing Office Code : 191111
Proposer Name : SUDEB MONDAL Issuing Office Name : Branch Office - North Kolkata
Address : C/O - MADHUSUDAN MONDAL ( Issuing Office Address : First floor, 229/2, Acharya Prafulla
NITYANANDA SARANI, P.O - Chandra Road,
BAMANGACHI, P.O - BARASAT Kolkata - 700 004
- 743248
.
Tel/Mobile : 033 - 25302533 / 25302534
.
E-mail Id : [email protected]
Chandrapur (CT),North Twenty
Four Parganas,West Bengal- Place of Supply : -
743248 Fulfiller Code : SH3271
Tel/Mobile : NIL/8276820306/
E-mail Id :
Intermediary Code : BA0000239311
Proposer GSTIN : - :
Name Mr.SUBODH DAS
Proposal date : 22-NOV-20
Date of Inception of first policy : 22-NOV-2016 Tel/Mobile : 9339239920/9339239920
Renewal Year : Fourth Year
E-mail Id :
Collection Number : 1143017020
Collection Date : 09/12/2020
Premium :Rs 3,673 /-
CGST @9% :Rs 331 /- SGST / UTGST @9% :Rs 331 /-
Stamp Duty :Re 1 /- Total Premium :Rs 4335 /-
Total Premium In Words : Rupees Four Thousand Three Hundred Thirty Five Only
PERIOD OF INSURANCE : FROM : 09/12/2020 18:48 TO : Midnight Of 08/12/2021 Policy Term : 1 Year

Details of Insured Persons : No. of Persons Insured: 1

Sl. Name Sex Date of Birth Age in Relationship Sum Insured Cumu.Bon ID Card No Pre Existing Inception
no. Yrs with Proposer (Rs.) us (Rs.) Disease Date

1 SUDEB MONDAL M 06/09/1983 37 SELF 200000 40000 6122635-1 No PED 22/11/2016

declared
Hospital Cash: No Patient Care: No

Optional Covers Opted : Gold Plan: No Hospital Cash:No Patient Care: No

Entered by : SH17414 For Star Health and Allied Insurance Company Ltd.

Approved by : SH17414

Authorised Signatory
IRDAI Regn. No 129
Corporate Identity Number U66010TN2005PLC056649
Email ID : [email protected] Please see overleaf 2 of 5

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/191111/01/2021/016228

THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC. ATTACHED.
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.
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.

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.

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 GOLAPI MONDAL Mother 27 100

Entered by : SH17414 For Star Health and Allied Insurance Company Ltd.

Approved by : SH17414

Authorised Signatory

Please see overleaf 3 of 5

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/191111/01/2021/016228

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 - North Kolkata on 09th
Day of December 2020.
Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

Entered by : SH17414 For Star Health and Allied Insurance Company Ltd.

Approved by : SH17414

Authorised Signatory

Please see overleaf 4 of 5

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. : 19I143Y21P000449 Customer ID : AA0004233402

Invoice Date : 09/12/20 Policy No : P/191111/01/2021/016228
Recipient Supplier

GSTIN : - GSTIN : 19AAJCS4517L1ZV

Proposer Name : SUDEB MONDAL NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - North Kolkata
Address : C/O - MADHUSUDAN MONDAL ( Address : First floor, 229/2, Acharya Prafulla
NITYANANDA SARANI, P.O - Chandra Road,
BAMANGACHI, P.O - BARASAT - Kolkata - 700 004
743248
.
.
City : Chandrapur (CT),North Twenty Four City : NORTH KOLKATA
Parganas,West Bengal-743248
State : West Bengal State : West Bengal
Pincode : 743248 Pincode : 700 006
Client Category : IND Place of Supply : 19 - West Bengal

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 G=C*Cess H=C+D+E+F+G
Code
*CGST *UTGST or
SGST
997133 Insurance 3673 0 3673 331 331 Rs. 4335 /-
Services
Total Invoice Value (in Figures) : Rs. 4335 /-
Total Invoice Value (in Words) : Rupees: Four thousand three
hundred thirty-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 : SH17414 For Star Health and Allied Insurance Company Ltd.

Approved by : SH17414

Authorised Signatory

Please see overleaf 5 of 5

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