IMPORTANT

To,

MR.A.C.RAJESH,
21/22, RUTHURAPPA NAGAR,
UDUMALPET - 642 126

Udumalaipettai,Coimbatore,Tamil Nadu-642126
Mobile : 8098508585.

Dear Customer,

Re: Health Insurance Policy - P/121111/01/2018/005271

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 stay in eligible room as stated in the policy, to avoid
payment of proportionate increased charges claimed by the hospitals, from your hand.

CN=S GANESAN,

S GANESAN SERIALNUMBER=6334c2e11098300722dbd61428bc9cb25d26f543b193f351fa3b
4910df34f5b9, ST=Tamil Nadu, OID.2.5.4.17=600034, OU="Management,CID -
4612742", OID.2.5.4.20
=14b18504069ddb5554096364e0c4b387c06b26ac5c1bce40fb105bb79531ea07
, O=STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED, C=IN Date:
2017.11.08 24:49:47 IST
 Family Health Optima Insurance Plan
Unique Identification No. IRDAI/HLT/SHAI/P-H/V.III/129/2017-18
Policy Schedule
Policy No. : P/121111/01/2018/005271 Previous Policy No. : P/121111/01/2017/005087
Customer Code : AA0000887167 GSTIN : 33AAJCS4517L1Z5
Customer Name : MR.A.C.RAJESH SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 1367955 Issuing Office Code : 121111
Proposer Name : MR.A.C.RAJESH Issuing Office Name : Branch Office -Sai Baba Clny Coimbatore
Address : 21/22, RUTHURAPPA NAGAR, Address : 1st Floor, 51/1 NSR Road, Sai Baba Colony,
UDUMALPET - 642 126 Coimbatore - 641 011

Udumalaipettai,Coimbatore,Tamil
Nadu-642126
Tel/Mobile : 8098508585/0 Tel/Mobile : 0422 - 4212592
E-mail id : rajeshacr@yahoo.com E-mail id : coimbatore.saibabaclny@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 12/11/2010 Fulfiller Code : SH5086
Date of Inception of first policy : 30-NOV-08
Intermediary Code : BA0000030134
Renewal Year : Ninth Year
Name : ARIVUKODI K A
Receipt No & Date : 1011006386 & 07/11/2017
Premium : Rs 10075 /- :
CGST @9% : Rs 907 /- SGST / UTGST @9% : Rs 907 /-
Tel/Mobile 9894439069/9894439069
Total Premium : Rs 11889 /- Stamp Duty : Re 1 /- : arivalaganinsurance@gmail.com
E-mail id
Total Premium In Words : Rupees Eleven Thousand Eight Hundred Eighty Nine Only

Period of insurance : From : 30/11/2017 00:00:00 To : Midnight of 29/11/2018

Basic Floater Sum Insured : 300000 Scheme Description : 2A+2C
In words : Rupees: Three Lakhs Only
Bonus: Rs. 135000 Limit of Coverage : Rs. 435000 Recharge Benefit : Rs. 75000
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 A C RAJESH M 15/03/1973 44 SELF 1367955-1 No PED declared 30/11/2008
2 S J JEYABAKYA F 20/04/1980 37 SPOUSE 1367955-2 No PED declared 30/11/2010
LAKSHMI
3 C R TEJO JEYAVIKRAM M 21/03/2014 3 DEPENDANT 1367955-3 No PED declared 30/11/2014
CHILD
4 C R SANGEERTHANAA F 22/02/2017 0 DEPENDANT 1367955-4 No PED declared 30/11/2017
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

Sector Classification

Urban

Entered By : SH43426 This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
IRDAI Regn. No 129 certificate NO: Adj/CS/277/102437/10
Corporate Identity Number U66010TN2005PLC056649
Email ID : support@starhealth.in Authorised Signatory
2 of 4
Attached to and forming part of Policy No. P/121111/01/2018/005271
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 .
"Consolidated Stamp duty paid vide G.O. Rt. No.238 dated 10.5.2017"
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office -Sai Baba Clny
Coimbatore on 07th Day of November 2017.

Entered By : SH43426 This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

Authorised Signatory
3 of 4
 Hospitalisation Benefit Policy
Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986

Policy No P/121111/01/2018/005271 Type Of Policy : Family Health Optima Insurance - 2017

Issue Office 121111 - Branch Office -Sai Baba Clny
Coimbatore
Address 1st Floor, 51/1 NSR Road, Sai Baba Colony,
Coimbatore - 641 011

Toll Free No 0422 - 4212592

Email coimbatore.saibabaclny@starhealth.in

This is to certify that MR.A.C.RAJESH has paid Rs 11889 (Total Premium In Words : Indian Rupees Eleven Thousand
Eight Hundred Eighty-Nine Only ) towards Premium for Hospitalization Insurance vide Policy No: P/121111/01/2018/005271
for the Period 30-NOV-17 To 29-NOV-18 issued on 07-NOV-17 .
Payment received by Cheque/Credit/Debit Card vide collection No:1011006386

Note :- This Certificate must be surrendred 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.

For Star Health and Allied Insurance Company Ltd.

Authorised Signatory

Entered By : SH43426 This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

Authorised Signatory
4 of 4