IMPORTANT

12/12/2022
To,

Mr.PRAMOD KUMAR,
102, Karishma classic appartment, srinivaspura cross
Channasandra, near dr Vishnuvardhan road
.
Bangalore,Bangalore,Karnataka -560098
Mobile : 9886653087.

Dear Customer,

Re: Health Insurance Policy - P/141146/01/2023/006069

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 :Mon Dec 12 21:45:59 IST 2022

1 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 : L66010TN2005PLC056649 Email :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129
 Family Health Optima Insurance Plan
SHAHLIP22030V062122

In consideration of payment of Rs.33712 /- towards renewal premium of Policy number: P/141146/01/2022/004600, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No : P/141146/01/2023/006069

GSTIN : 29AAJCS4517L1ZU
Customer Code : AA0010578480
Customer Name : Mr.PRAMOD KUMAR SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 13336699 Issuing Office Code : 141146
Proposer Name : Mr.PRAMOD KUMAR Issuing Office Name : Branch Office - Rajajinagar 3
Address : 102, Karishma classic appartment, Address : " Indra Arcade " # 81, 1st Floor,
srinivaspura cross Dr Rajkumar Road, Prakashnagar,
Channasandra, near dr Rajajinagar 3rd Stage, Bangalore 560 021
Vishnuvardhan road
.
Bangalore,Bangalore,Karnataka -560098
Tel/Mobile : 9886653087/9886653087/ Tel/Mobile : 080 4943 8000
E-mail id : [email protected] E-mail id : [email protected]
Proposer GSTIN : - Place of Supply : -
Proposal date : 11/01/2020 Fulfiller Code : SH14274
Date of Inception of first policy : 11-JAN-2020
Intermediary Code : BA0000109770
Renewal Year : Third Year
Collection Number & : 1747006254 & 12/12/2022 Name : GANGADHARAPPA
Date
Basic Cover : Rs 28570 /- Tel/Mobile : /9880458680
Section 1(Extra Protect Add-on Cover) : Rs /-
Section 2(Extra Protect Add -on Cover) : Rs 0 /- : GANGADHARGOWDA.LIC@G
E-mail id
Premium : Rs 28570 /-
MAIL.COM
CGST @9% : Rs 2,571 /- SGST / UTGST @9% : Rs 2,571 /-
Total Premium : Rs 33712 /- Stamp Duty : Re 1 /-
Total Premium In Words : Rupees Thirty Three Thousand Seven Hundred Twelve Only
Installment Facility Optn :No Premium Payment Frequency :Annual Installment Amount Rs. : 0

Period of insurance : From : 11/01/2023 00:00 To : Midnight of 10/01/2024

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 PRAMOD KUMAR M 17/01/1965 57 SELF 13336699-1 11/01/2020
Pre Existing Disease : All complications directly or indirectly related to the surgeries or procedures performed previously-GLOBE
EXPLORATION  WITH GLOBE REPAIR AND EYELID REPAIR 
Ophthalmological diseases & their complications
2 PRADNYA PRAMOD F 19/04/1973 49 SPOUSE 13336699-2 No PED declared 11/01/2020
PANDURANGI

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

2 of 4
 Attached to and forming part of Policy No. P/141146/01/2023/006069

3 ROHIT P PANDURANGI M 10/09/2007 15 DEPENDANT 13336699-4 No PED declared 11/01/2020

CHILD
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 NAVEEN P PANDURANGI Son 25 100

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).

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: [email protected], Fax No: 1800 425 5522 .
"CONSOLIDATED STAMP DUTY FOR POLICY STAMPS PAID VIDE ORDER NO. IG1122003053018252 DT 29.11.2022"

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 - Rajajinagar 3 on
12th Day of December 2022.

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

3 of 4
 TAX Invoice

Invoice No. : 29I747Y23P000355 Customer ID : AA0010578480

Invoice Date : 12/12/22 Policy No : P/141146/01/2023/006069
Recipient Supplier

GSTIN : - GSTIN : 29AAJCS4517L1ZU

Proposer Name : Mr.PRAMOD KUMAR NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Rajajinagar 3
Address : 102, Karishma classic appartment, Tel/Mobile : " Indra Arcade " # 81, 1st Floor,
srinivaspura cross Dr Rajkumar Road, Prakashnagar,
Channasandra, near dr Rajajinagar 3rd Stage, Bangalore 560 021
Vishnuvardhan road
.
City : City : RAJAJINAGAR 3
State : Karnataka State : Karnataka
Pincode : 560098 Pincode : 560021
Client Category : IND Place of Supply : 29 - Karnataka

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 28570 0 28570 2571 2571 Rs. 33712

Total Invoice Value (in Figures) : Rs. 33712
Total Invoice Value (in Words) : Rupees: Thirty-three thousand
seven hundred twelve 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 : [email protected]

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

4 of 4