ACCIDENT CARE INDIVIDUAL INSURANCE POLICY

Unique Identification No:IRDAI/HLT/SHAI/P-P/V.III/134/2017-18

Schedule
Policy No. : P/151118/02/2019/002187 Previous Policy No. :
Customer Code : CB0000048825 GSTIN : 27AAJCS4517L1ZY
Customer Name : M/S.SRD ENTERPRISES SAC CODE : 997133/Accident and Health Insurance Services
Proposer's Code 9819758 Issuing Office Code : 151118
:
Issuing Office Name : Branch Office-Pimpri
Proposer Name : ANIL KAMAJI SHINDE
Issuing Office Address : Premises No. 6 & 7, 13 & 14, Sunshine
Address : RAMDAS NAGAR, ROAD NO. 1, Plaza,
NEAR SAI MANDIR
CTS NO - 4713, Near Ambedkar
TALUKA HAVELI Chouk,Station Road
CHIKHALI PUNE Above Ratna Hotel,Pimpri, Pune - 411018
Pimpri
Chinchwad,Pune,Maharashtra-
412114
Tel/Mobile : 7972908217/9011875353/ Tel/Mobile : 020-67187610/11/12/14
Email id : sharaddjathar@gmail.com Email id : pimpri.pune@starhealth.in
Proposer GSTIN : - Place of Supply : Maharashtra / State Code : 27
Date of Inception of first policy : 18-SEP-2018 Fulfiller Code : SH6977
Renewal Year : NEW :
Intermediary Code BA0000113644
Receipt No : 1212014068
Name : Ms.ATTARDE MAMTA
Collection Date : 18/09/2018
Premium : Rs.1300 /-
Phone : 9403724852/9422227592
CGST @9% : Rs.117 /- SGST / UTGST @9% : Rs.117 /-

Email id : attardenitin2005@gmail.com
Stamp Duty : Rs . 50 /- Total Premium : Rs . 1534 /-
Total Premium In Words : Indian Rupees One Thousand Five Hundred Thirty Four Only
Period of Insurance : From 18/09/2018 00:00 To Midnight Of 17/09/2019
Total Sum Insured : Rs . 1000000 /-
In words : Rupees Ten Lakhs Only.

Insured Details :
Sl. Name of the Insured Gender DOB Age Relation with Occupation Risk Group Pre- Cumulative Inception
No in yrs proposer existing Bonus Rs. Date
Disabilities
1 ANIL KAMAJI SHINDE M 02/02/1988 30 SELF SERVICE Risk Group II NIL 0 18-SEP-18

Entered by : SH47564 Approved by : SH47564

For Star Health and Allied Insurance Company Ltd.

Place : PIMPRI
:

Authorised Signatory

IRDAI Regn. No 129 CN=R Margabandhu,

R Margabandhu
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b154
75488cdf3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,
Corporate Identity Number U66010TN2005PLC056649 OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806c
a65f89e15179f5fe50a, OU=UNDERWRITING - Chief Risk Officer,
O=STAR HEALTH AND ALLIED INSURANCE COMPANY, C=IN.
Date :Thu Oct 01 22:11:43 IST 2020 1 of 2
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
Attached to and forming part of Policy No: P/151118/02/2019/002187

Coverage Details :

Sl. Sum Insured (Rs.) Optional Benefits opted

No Name of the Insured Table A Table B Table C Total Medical Hospital Home Winter
Expenses Cash Convalescence Sports
Extension
1 ANIL KAMAJI SHINDE 0 1000000 0 1000000 No No No No

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 SADHANA ANIL SHINDE Spouse 29 100

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(s) 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 ab-initio
(from inception).
General Condition No. 2 regarding Claims Settlement shall read as follows and not as stated in policy wordings:
"The Company shall pay interest as per Insurance Regulatory and Development Authority of India (Protection of Policyholders' Interests)
Regulations, 2017, in case of delay in payment of an admitted claim under the Policy"

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

Important
Intimation about an event or occurrence that may give rise to a claim under this policy must be given within 30 days of its happening. Toll Free No:
1800 425 2255/1800 102 4477 Email: support@starhealth.in Fax No: 1800 425 5522

NOTE : Kindly note that the settlement of claims under the Policy are subject to the provisions of Anti- Money Laundering / Counter
Financing of Terrorism (AML/CFT) policy of the Company. For further details, please visit our website www.starhealth.in

"Consolidated stamp paid vide certificate No.CSD/61/2018/2402-03/18 Dt. 28.06.2018"

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office-Pimpri on 21st Day of
September 2018.

Entered by : SH47564 Approved by : SH47564

For Star Health and Allied Insurance Company Ltd.

Place : PIMPRI
:

Authorised Signatory

2 of 2

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