Branch Office - Dehradun AS-5, 6 & 7, PLS Plaza, 2nd Floor, 4B Raja Road , Dehradun - 248 001.

, , , 248 001

Advance Premium Receipt

Customer Code : AA0006019994 Receipt No : 5H117Y19R0000100

Received from : NISHIT SRIVASTAV Receipt Date : 05/11/2018

Customer Address : 131, KASHMIRI COLONY, INDIRA GANDHI MARG Collection No : 11-01/1117009382

NIRANJANPUR, DEHRADUN Collection Date : 05/11/2018

Office Code : 161115 - Branch Office - Dehradun

Supplier GSTIN : 05AAJCS4517L1Z4

Customer GSTIN : - Place of Supply : - State Code: -

Amount Collected : Rs. 15034 /- Inclusive of tax : CGST @9%- Rs. 1146/- SGST/UTGST @9%- Rs. 1146

Amount in words : Indian Rupees Fifteen Thousand Thirty-Four Only SAC code : 99713

Towards the Following : PREMIUM RECEIPT ONLINE POLICY

S. No. Proposal Ref. No Fulfiller Code Intermediary Code Amount Collected Mode of Pay Bank Name CHQ/CC/DD No CHQ/DD/BC Dt

1 R/161115/01/2019/009822 SH12369 BA0000294156 15034 CC BANK 8162235414 05/11/2018

For Star Health and Allied Insurance Co. Ltd

Note : Receipt Subject to realization of Cheque / DD

This is only an evidence of receipt of money by the company
Risk will commence once the proposal is examined and accepted Authorised Signatory

Amount of Tax Subject to reverse Charge : No

CN=SRINIVASAN RAMASWAMY,

SRINIVASAN SERIALNUMBER=91fa1f6086f94760c8858bf1d653fa94cf9b2caaf7d01
926c03552012536da26,
OID.2.5.4.20=b9b82e818a1c0f85a0f74b8e131a80293ef1084f20a913bd
c1f47ed182afbf8c, ST=Tamil Nadu, OID.2.5.4.17=600034, OU=CHIEF

RAMASWAMY FINANCIAL OFFICER, O=STAR HEALTH AND ALLIED INSURANCE

COMPANY LIMITED, C=IN. Date :Mon Nov 05 12:34:01 IST 2018

IRDA Regn. No 129 Corporate Identity Number U66010TN2005PLC056649 Email id : info@starhealth.in

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