Star Health And Allied Insurance Company Limited

Date : 12-Aug-2022
To, IMPORTANT

Mr. VENKATESWARA RAO KAMBHAMPATI ,

2nd Floor Vaikuntam Plot No : 79, CRR Puram,
L&T Colony II nd Main Road, Manapakkam
CHENNAI
Chennai,Tamil Nadu-600125
Mobile : 9840165834

Dear Customer,

Re: Health Insurance Policy - 11230076563703

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

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,
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b15475488cdf

R Margabandhu 3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,

OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806ca65f89e15
179f5fe50a, OU=UNDERWRITING - Chief Risk Officer, O=STAR HEALTH AND
ALLIED INSURANCE COMPANY, C=IN. Date :Fri Aug 12 11:44:55 IST 2022
Page 1 of 5

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 : L66010TN2005PLC056649 Email :support@starthealth.in
Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Family Health Optima Insurance Plan

Unique Identification No. SHAHLIP22030V062122

In Consideration of payment of Rs. 34,557/- towards renewal premium of policy

number:P/111116/01/2022/008995, the policy stands renewed for a further period of 1 Year as per
the details given below

Renewal Endorsement No:11230076563703

Customer Code : 11947946 GSTIN : 33AAJCS4517L1Z5
Customer Name : Mr. VENKATESWARA RAO SAC Code : 997133 / Accident and Health
KAMBHAMPATI Insurance Services
Proposer Code : 11947946 Issuing Office Code : 111116
Proposer Name : Mr. VENKATESWARA RAO Issuing Office Name : Branch Office -
KAMBHAMPATI Kodambakkam
Proposer Address : 2nd Floor Vaikuntam Plot No : 79, Issuing Office Address : NO: 36,KALPALATHIKKA
CRR Puram, TOWERS 1ST
L&T Colony II nd Main Road, FLOOR, Dr.AMBEDKAR ROAD,
Manapakkam OPP:GRACE SUPER MARKET,
CHENNAI NEAR : AGARWAL EYE
Chennai Tamil Nadu 600125 HOSPITAL,
KODAMBAKKAM, CHENNAI-
600024
Chennai Tamil Nadu 600024
Phone No : 9840165834 Phone No : 044-49064103/044-
49064104/044-49064105
E-mail Id : lalit_venkat@yahoo.com E-mail Id : chennai.kodambakkam@starh
ealth.in
Proposer GSTIN : NO Place of Supply : Tamil Nadu
Proposal date : 17-Aug-2019 Fulfiller Code : SH1937
Date of Inception : 23-Aug-2017
of first policy
Renewal Year : Third Year Intermediary :BA0000003902
Collection No : 181062009318
Code
Collection Date : 12-Aug-2022 Name :Mr.M.
Premium : Rs. 29,285/- KRISHNAMURTHY
CGST @ 9% : Rs. 2,636/-
Phone No :9884193159
:
SGST @ 9% Rs. 2,636/-
E-mail Id : mkcbo31@gmail.com
Total Premium : Rs. 34,557/-
Stamp Duty : Re. 1/-

Total Premium In Words : Rupees Thirty Four thousand five hundred fifty
seven only
PERIOD OF INSURANCE : From : 23-Aug-2022 00:00 To : Midnight Of 22-Aug-2023
Installment Facility Option:No Premium Payment Frequency :Annual Installment Amount Rs. : 0/-

Basic Floater Sum Insured : Rs. 10,00,000/- Scheme Description : 2A+1C

In Words : Rupees Ten lakhs only
Bonus : Rs. 3,25,000/- Limit of Coverage : Rs. 13,25,000/- Recharge Benefit : Rs. 1,50,000/-

Entered by : CUSTPORTAL For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL
IRDA Regn.No.129

Corporate Identity Number L66010TN2005PLC056649

Authorised Signatory Page 2 of 5
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 : L66010TN2005PLC056649 Email :support@starthealth.in
Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Attached to and forming part of Policy No: 11230076563703

Details of Insured Persons :
Sl. Age in Relationship Inception
Name of the Insured Gender Date of Birth ID Card No
no. Yrs with Proposer date
Mr. VENKATESWARA RAO
1 KAMBHAMPATI Male 01-Jun-1968 54 Self 11947946-1 23-Aug-2017

Pre Existing Disease : Hypertension and its complications

Diabetes Mellitus and its complications
Mrs. K. SRIDEVI
2 Female 26-Jun-1970 52 Spouse 11947946-2 23-Aug-2017

Pre Existing Disease : No PED Declared

Miss. K. KRISHNA ANUSHA
3 Female 11-Feb-2001 21 Daughter 11947946-3 23-Aug-2017

Pre Existing Disease : No PED Declared

Nominee Details:
Nominee Details for the Proposer Appointee Details
S.No Name Relationship Age % of the Appointee Name Appointee Relationship
with proposer claim Age with nominee

1 K. SRIDEVI Spouse 52 100

Sector Classification:
Urban No

''CONSOLIDATED STAMP DUTY PAID VIDE G.O.(RT) NO.173 DATED.10TH MAY 2022''

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).
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.
Toll Free No : 1800 425 2255 / 1800 102 4477 Email: support@starhealth.in, Fax No: 1800 425 5522.
It is hereby made clear that all terms, conditions, clauses, warranties, exclusions etc., as already issued, forming
part of the policy of insurance originally issued at the time of inception of this relationship, shall continue to be
operative and unaltered, forming part of this renewal insurance cover also.

Reference may be made to those terms, conditions etc., for identifying the scope/extent of coverage.

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch
Office - Kodambakkam on 12th Day of August 2022.

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

Authorised Signatory Page 3 of 5

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 : L66010TN2005PLC056649 Email :support@starthealth.in
Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Hospitalisation Benefit Policy

Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986

Policy No : 11230076563703 Type of Policy : Family Health Optima Insurance

Plan - 2021
Issue Office : 111116-Branch Office - Kodambakkam

Address : NO: 36,KALPALATHIKKA TOWERS 1ST FLOOR, Dr.AMBEDKAR ROAD,

OPP:GRACE SUPER MARKET, NEAR : AGARWAL EYE HOSPITAL,
KODAMBAKKAM, CHENNAI-600024
Chennai Tamil Nadu 600024

Tel / Fax : 044-49064103/044-49064104/044-49064105

Email : chennai.kodambakkam@starhealth.in

This is to certify that Mr. VENKATESWARA RAO KAMBHAMPATI has paid Rs 34,557/- (Total Premium :
Indian Rupees Thirty Four thousand five hundred fifty seven only ) towards Premium for Hospitalization
Insurance vide Policy No: 11230076563703 for the Period 23-Aug-2022 To 22-Aug-2023 issued on 12-Aug-
2022.
Payment received by Payment Gateway vide Receipt No: 181062009318/1 Receipt Date: 12-Aug-2022

Note :- This Certificate must be surrendered to the Insurance Company for issuance of fresh Certificate in
case of Cancellation of the Policy or any alteration in the Insurance affecting the Premium.

Date : 12-Aug-2022 For and on behalf of

Place : Branch Office - Kodambakkam Star Health and Allied Insurance Company Ltd.

IRDA Regn.No.129

Corporate Identity Number L66010TN2005PLC056649 Authorised Signatory

Email ID: info@starhealth.in

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

Authorised Signatory Page 4 of 5

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 : L66010TN2005PLC056649 Email :support@starthealth.in
Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Tax Invoice
Invoice No. : 332208I002906744 Customer ID : 11947946
Invoice Date : 12-Aug-2022 Policy No. : 11230076563703
Recipient Supplier
GSTIN : NO GSTIN : 33AAJCS4517L1Z5
Name : Mr. VENKATESWARA RAO Name : Star Health and Allied Insurance Co Ltd -
KAMBHAMPATI Branch Office - Kodambakkam
Address : 2nd Floor Vaikuntam Plot No : 79, CRR Address : NO: 36,KALPALATHIKKA TOWERS 1ST
Puram, FLOOR, Dr.AMBEDKAR ROAD,
L&T Colony II nd Main Road, OPP:GRACE SUPER MARKET, NEAR : AGARWAL
Manapakkam EYE HOSPITAL,
CHENNAI KODAMBAKKAM, CHENNAI-600024
City : Chennai Pin Code : 600125 City : Chennai Pin Code : 600024

State : Tamil Nadu Client : IND State : Tamil Nadu Place of : Tamil Nadu
Category supply

Taxable IGST @ UT/SGST @ CESS @ Total Invoice

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

Insurance
997133 29,285.00 0 29,285.00 0 2,636.00 2,636.00 0 34,557.00
Services

Total Invoice Value (in Figures) : Rs. 34,557/-

Total Invoice Value (in Words) : Rupees Thirty Four thousand five hundred fifty seven 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

IRDA Regn.No.129 Corporate Identity Number L66010TN2005PLC056649 Email ID: stargst@starhealth.in

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

Authorised Signatory Page 5 of 5

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 : L66010TN2005PLC056649 Email :support@starthealth.in
Website :www.starhealth.in IRDAI Regn.no: 129