Branch Office - Bhimavaram 27-1-6, 1st floor, Pattabhi Plaza , Backside of SBI (ADB) Branch , JP Road, Bhimavaram ,

Hyderabad , 534202
Collection Receipt
Customer Code : AA0005726919

Received from : Mr.SAMAYAMANTHULA SRIHARSHAVARDHAN

Customer Address : 31-43_1/1 plot no:67 Collection No : 11-01/1411004718

MATHRU SREE NAGAR PHASE-2 KURMANNA PALEM Collection Date : 29/09/2020

OLD GAJUWAKA, VISAKHAPATNAM Office Code : 131134 - Branch Office - Bhimavaram

Supplier GSTIN : 37AAJCS4517L1ZX

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

Amount Collected : Rs. 9599 /- Inclusive of tax :

Amount in words : Indian Rupees Nine Thousand Five Hundred Ninety-Nine 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/131134/01/2021/006279 SH17772 BA0000122556 9599 CC UPI 11218383669 29/09/2020

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 :Tue Sep 29 20:41:04 IST 2020

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