Corona Kavach Policy,Star Health and Allied Insurance Co.

Ltd
Unique Identification No. SHAHLIP21066V012021
Certificate of Insurance

Certificate no : P/141223/01/2021/001308 Previous Certificate :

no
Customer Code : AA0013525597 GSTIN : 29AAJCS4517L1ZU
Customer Name : RONALD MELWIN VEIGAS SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 16437622 Issuing Office Code : 141223
Proposer's Name : RONALD MELWIN VEIGAS Issuing Office Name : Branch Office - Moodbidri
Address : House no 6-25/1, S/o ROSARIO Address : Pancharathna Business Centre,
VEIGAS RONALD VILLA Near Alvas Health Centre,
NAGURI, ANJELORE, Moodbidri - 574227
MANGALORE Phone No : 08258-298331
E-mail Id : moodbidri@starhealth.in
Mangalore,Dakshina
Kannada,Karnataka-575002 Place of Supply : -
Phone No : /9108230414/ Fulfiller Code : SH27574
E-mail Id : REONCONSULTANCY@GMAIL.C Intermediary Code : BA0000233031
OM
Proposer GSTIN : - :
Name Mrs.HENCIL R N DSOUZA
Proposal date : 25/07/2020
Date of Inception of first policy : 25/07/2020 Phone No : 9448216661/9448216661
Renewal Year : NEW
E-mail Id : ronylic@gmail.com
Collection Number : 1437001432
Receipt Date : 25/07/2020
Premium :Rs 2,281 /-
CGST @9% :Rs 205 /- SGST / UTGST @9% :Rs 205 /-
Stamp Duty :Rs 1 /- Total Premium :Rs 2691 /-
Total Premium In Words : Rupees Two Thousand Six Hundred Ninety One Only

PERIOD OF INSURANCE : 25/07/2020 18:43:00 TO : Midnight Of 06/05/2021 No. of Days : 285

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

Sex Date of Birth Age in Relationship Optional Inception Date

Sl.n Name of the Insured Sum Insured (Rs.) ID Card No Pre-existing
Yrs Cover Opted
o. with Proposer Y/N Disease/s

1 RONALD MELWIN VEIGAS M 05/02/1967 53 SELF 500000 No 16437622-1 NONE 25/07/2020

For detailed coverage, terms & Conditions and exclusions, kindly visit website : www.starhealth.in

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 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 Chennai on 25th Day of July 2020.

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

Authorised Signatory
IRDAI Regn. No 129
Corporate Identity Number U66010TN2005PLC056649 CN=R Margabandhu,

R Margabandhu
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b154
75488cdf3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,
OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806c

Email ID : info@starhealth.in a65f89e15179f5fe50a, OU=UNDERWRITING - Chief Risk Officer,

Please see overleaf
O=STAR HEALTH AND ALLIED INSURANCE COMPANY, C=IN.
Date :Sat Jul 25 18:56:05 IST 2020 1 of 1

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