Branch Office - Indore- IV SATGURU PARINAY, Office No. 504-505 , 5th Floor, Near Pakiza Showroom,Scheme No.

54, , Opp.
C21 Mall, A. B. Road, , INDORE , 462011
Collection Receipt
Customer Code : AA0011543962

Received from : SUMAN YADAV

Customer Address : Plot no.67 sector-b slice-5 Collection No : 11-01/1320009072

SCHEME NO 78 vijay nagar Collection Date : 24/03/2022

Office Code : 201123 - Branch Office - Indore-IV

Supplier GSTIN : 23AAJCS4517L1Z6

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

Amount Collected : Rs. 19355 /- Inclusive of tax :

Amount in words : Indian Rupees Nineteen Thousand Three Hundred Fifty-Five Only

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/201123/01/2022/024036 SH35686 BA0000260121 19355 CC HDFC Bank 220324031926 24/03/2022

390742

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

CN=R Margabandhu,

R Margabandhu
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b15
475488cdf3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,
OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806
ca65f89e15179f5fe50a, OU=UNDERWRITING - Chief Risk Officer,
O=STAR HEALTH AND ALLIED INSURANCE COMPANY, C=IN.
Date :Thu Mar 24 21:42:48 IST 2022

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@starhealth.in Website :www.starhealth.in IRDAI Regn.no: 129