IMPORTANT

To, 17-AUG-21

REENA SHARMA
TARUN STATIONARY
SHARMA MARKET,SETOR-22,NEAR ESIC HOSPITAL,NOIDA

Noida,Gautam Buddha nagar,Uttar Pradesh -201301

Mobile : 7701819654.

Dear Customer,

Re: Health Insurance Policy - P/161121/01/2022/013820

We are extremely thankful to you for your renewal instructions and payment of premium. We enclose the renewed
policy based on our records. We would request you to kindly study the renewed policy carefully and revert to us if
there is any discrepancy to enable us to attend to the same.

Kindly note that the above request is very important and if we do not hear anything from you within 15 days, we
would presume that the policy issued by us is in order and the contract is concluded.

We would like to mention that we have incorporated the name of the intermediary as indicated by you.

We wish you good health and we look forward to serve you in the days to come.

With kind regards,

Authorised Signatory
"Let Star Health help you to become healthier and happier. Star Wellness Benefits includes Mind Body healing and other
Condition management programmes (Weight management, Diabetes etc....) Visit www.starhealth.in / customer portal login and
start your journey with us to Better Health".

In case of a need for hospitalization, kindly prefer our network hospital (list is available in our website) for a quick
response to your claim request.

Please select the room as per your eligibility stipulated in your policy to avoid additional payment from your
pocket towards the proportionate increase which would invariably be charged by the hospital for the higher
room category occupied.

Sum insured of this Policy is meant for utilization till its expiry. Bearing this aspect in mind, we have no doubt, you
will choose appropriate hospital, room rent and treatment charges, etc.

Should you need any assistance, our customer care will be delighted to assist you, whose toll free no. is 1800-425-
2255/1800-102-4477.

However, the ultimate decision will be that of yours only.

CN=R Margabandhu,

R Margabandhu
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b154
75488cdf3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,
OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806c
a65f89e15179f5fe50a, OU=UNDERWRITING - Chief Risk Officer,
O=STAR HEALTH AND ALLIED INSURANCE COMPANY, C=IN.
Date :Fri Aug 20 22:52:51 IST 2021

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
 YOUNG STAR INSURANCE POLICY
SCHEDULE (Floater)
UNIQUE ID:SHAHLIP22036V042122
Policy No. : P/161121/01/2022/013820 Previous Policy No. : P/161121/01/2021/011986
Customer Code : AA0014219928 GSTIN : 09AAJCS4517L1ZW
Customer Name : REENA SHARMA SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 17154768 Issuing Office Code : 161121
Proposer's Name : REENA SHARMA Issuing Office Name : Branch Office - Noida
Address : TARUN STATIONARY Address : Office No-606/607
SHARMA MARKET,SETOR- 6th Floor, P3, Krishna Apra Plaza,
22,NEAR ESIC HOSPITAL,NOIDA Sector-18, Noida-201301

Noida,Gautam Buddha nagar,Uttar

Pradesh-201301
Phone No : /7701819654/ Phone No : 0120-6618401, 02, 03
E-mail Id : raghavsharma.770181@gmail.com E-mail Id : noida@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 18/08/2020 Fulfiller Code : SH49690

Date of Inception of first policy : 18-AUG-2020 Intermediary Code : BA0000452537

Renewal Year : First Year
Receipt Date : 17/08/2021 Name : Mrs.NICKEY KUMARI
Premium :Rs 10,243 /-
CGST @9% : 896 /- SGST / UTGST @9% : 896 /- Phone No : 8742953048/8742953048
Stamp Duty :Rs 1 /- Total Premium :Rs 12,035 /-
E-mail Id : GOVIND2190@YAHOO.C
OM
Total Premium In Words : Rupees Twelve Thousand Thirty Five Only Installment Facility Optn :Yes

Premium Payment Frequency :Semi - Annual Installment Amount Rs. : 6018 Collection No: 1165016124

Period of Insurance : FROM 18/08/2021 00:00 TO : Midnight Of 17/08/2022 Term : 1 Year

Scheme Description (Family Size) : 1 ADULT + 1 CHILD Basic Floater Sum Insured : Rs. 500000 /-
Bonus : Rs. 100000 /-
Total Sum Insured In Words : Rupees Five Lakhs Only Plan Type : GOLD
Details of Insured Persons :
Sl. Name of the Insured Sex Date of Birth Age in Relationship with ID Card No Pre Existing Disease Inception Date
no. Yrs Proposer
1 REENA SHARMA F 08/11/1983 37 SELF 17154768-1 18/08/2020
Pre Existing Disease :
Diseases of the upper GI tract and their complications
Hypertension and its complications
2 RAGHAV SHARMA M 27/08/2004 16 DEPENDANT CHILD 17154768-2 No PED 18/08/2020
declared

Entered by : SH43622 For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL

IRDAI Regn. No 129

Authorised Signatory
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
2 of 4

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/161121/01/2022/013820

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 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 abinitio
(from inception).

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

Toll Free No: 1800 425 2255/1800 102 4477 Email: support@starhealth.in, Fax No: 1800 425 5522

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 RAGHAV SHARMA Son 17 100 SHIV 68 Grand Father

NARAYAN
TIWARI

In witness whereof the undersigned being authorised by and on behalf of the company has set his hand at Branch Office - Noida on 17th
Day of August 2021.

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

INSTALLMENT PREMIUM CLAUSE

Sr.No. Installment Due Dt. Premium Amount GST Amount Total Installment Premium Amount

1 18-AUG-21 5122 896 6018

2 17-FEB-22 5122 896 6018
Total : 10243 1792 12035

Entered by : SH43622 For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL

Authorised Signatory

3 of 4

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
 TAX Invoice

Invoice No. : 9E165Y22P0001431 Customer ID : AA0014219928

Invoice Date : 17/08/21 Policy No : P/161121/01/2022/013820
Recipient Supplier

GSTIN : - GSTIN : 09AAJCS4517L1ZW

Proposer's : REENA SHARMA NAME : Star Health and Allied Insurance Co Ltd
Name - Branch Office - Noida
Address : TARUN STATIONARY Address : Office No-606/607
SHARMA MARKET,SETOR- 6th Floor, P3, Krishna Apra Plaza,
22,NEAR ESIC HOSPITAL,NOIDA Sector-18, Noida-201301

City : Noida,Gautam Buddha nagar,Uttar City : NOIDA

Pradesh-201301
State : Uttar Pradesh State : Uttar Pradesh
Pincode : 201301 Pincode : 201301
Client Category : IND Place of Supply : 9 - Uttar Pradesh

HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% CESS@1% Total Invoice Value
SAC Service(s) G=C*Cess H =C+D+E +F+G
Code A B C=A-B D = C * IGST E=C F=C
*CGST *UTGST or
SGST

997133 Insurance 10243 0 10243 896 896 Rs. 12035

Services
Total Invoice Value (in Figures) : Rs. 12035
Total Invoice Value (in Words) : Rupees: Twelve thousand thirty-
five only
Amount of Tax Subject to reverse Charge : No

Important Note:

The invoice is issued as per Section 31 of the CGST Act

In case no GSTIN or incorrect GSTIN is provided by the Proposer at Proposal stage, Star Health and Allied Insurance Co Ltd shall not be
responsible for any Input Tax Credit losses and no subsequent revision of invoice will be undertaken.

E. & O.E
This is a digitally signed document and hence no physical signature is required

IRDAI Regn. No 129 Corporate Identity Number U66010TN2005PLC056649 Email ID : stargst@starhealth.in

Entered by : SH43622 For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL

Authorised Signatory

4 of 4

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