IMPORTANT

To,

VEMULA RAMESH BABU,

V Ramesh babu, door no 6-44, Pathamajeru
Challapalli mandal krishna dist

Bhogireddipalle,Krishna,-521131
Mobile : 9444961798.

Dear Customer,

Re: Health Insurance Policy - P/171116/01/2022/015156

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 stay in eligible room as stated in the policy, to avoid
payment of proportionate increased charges claimed by the hospitals, from your hand.

CN= AGARA M ALLEGOWD A M ALLESH ,

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OID.2.5.4.20= 9faf86b6b361d64e4c d62938c 6e1325d59597414ba783c 8768
MALLESH f251f1c a0a418f, ST =T amil N adu, OID.2.5.4.17= 600034, OU =EXEC UTIVE
DIR ECT OR, O= ST AR H EALT H AND ALLIED IN SU R AN C E C OM PAN Y
LIM IT ED , C=IN . D ate :Wed M ay 07 17:46:34 IST 2022
 Family Health Optima Insurance Plan
Unique Identification No. IRDAI/HLT/SHAI/P-H/V.III/129/2021-22
Policy Schedule
Policy No. : P/171116/01/2022/015156 Previous Policy No. : P/700002/01/2021/097622
Customer Code : AA0004798302 GSTIN : 27AAJCS4517L1ZY
Customer Name : VEMULA RAMESH BABU SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 6752223 Issuing Office Code : 171116
Proposer Name : VEMULA RAMESH BABU Issuing Office Name : Branch Office - Ghatkopar
Address : V Ramesh babu, door no 6-44, Address : Room No: 110-111-112, Sanghvi Square,
Pathamajeru Opp: Bank of Baroda,
Challapalli mandal krishna dist M. G. Road, Ghatkopar (West), Mumbai - 400
086.
Bhogireddipalle,Krishna,-521131
Tel/Mobile : /9444961798/ Tel/Mobile : 022 - 42267000
E-mail id : ramesh_v54@yahoo.com E-mail id : ghatkopar.mumbai@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 16/05/2021 Fulfiller Code : SO171116
Date of Inception of first policy : 17-MAY-21
Intermediary Code : LC0000000351
Renewal Year : First Year
Name : M/S.COVERFOX INSURANCE
Receipt No & Date : 1173016112 & 07/05/2022
Premium : Rs 21875 /- BROKING PVT. LTD.
IGST @18% : Rs 3,938 /-
: 1800 209 9970/1800 209 9970
Total Premium : Rs 25813 /- Stamp Duty : Re 1 /- Tel/Mobile
E-mail id : Contact@coverfox.com
Total Premium In Words : Rupees Twenty Five Thousand Eight Hundred Thirteen Only

Period of insurance : From : 17/05/2022 00:00:00 To : Midnight of 16/05/2023

Basic Floater Sum Insured : 500000 Scheme Description : 2A
In words : Rupees: Five Lakhs Only
Bonus: Rs. 125000 Limit of Coverage : Rs. 625000 Recharge Benefit : Rs. 150000
Details of Insured Persons :

Sl. Name of the Insured Gender Date of Birth Age in Relationship ID Card No Pre-existing Disease Inception Date
No. Yrs with Proposer

1 Vemula Ramesh babu M 28/04/1989 33 Self 6752224-1 No PED declared 17/05/2022

PED : No PED declared

2 Jogi Indra Varsha F 25/08/1998 25 Wife 6752224-2 No PED declared 17/05/2022

Nominee Details

Nominee Details for the proposer Appointee Details

Relationship Age % of Appointee Relationship

S.No. Name Age
with proposer the Name with Nominee
claim

1 VEMULA PADHMA VATHI Mother 53 100

Sector Classification

Rural

Entered By : PREMIA This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
IRDAI Regn. No 129 certificate NO: Adj/CS/277/102437/10
Corporate Identity Number U66010TN2005PLC056649
Email ID : support@starhealth.in Authorised Signatory
2 of 4
Attached to and forming part of Policy No. P/171116/01/2022/015156
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.

Toll Free No : 1800 425 2255 / 1800 102 4477 Email: support@starhealth.in, Fax No: 1800 425 5522 .
"Consolidated stamp paid vide certificate No.CSD/225/2021/4540/17 Dt.08.11.2021"
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Ghatkopar on 07th
Day of May 2022.

Entered By : PREMIA This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

Authorised Signatory
3 of 4
 Hospitalisation Benefit Policy
Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986

Policy No P/171116/01/2022/015156 Type Of Policy : Family Health Optima Insurance - 2012

Issue Office 171116 - Branch Office - Ghatkopar
Address Room No: 110-111-112, Sanghvi Square,
Opp: Bank of Baroda,
M. G. Road, Ghatkopar (West), Mumbai -
400 086.

Toll Free No 022 - 42267000

Email ghatkopar.mumbai@starhealth.in

This is to certify that VEMULA RAMESH BABU has paid Rs 25813 (Total Premium In Words : Indian Rupees Twenty
Five Thousand Eight Hundred Thirteen Only ) towards Premium for Hospitalization Insurance vide Policy No:
P/171116/01/2022/015156 for the Period 17-MAY-22 To 16-MAY-23 issued on 07-MAY-22 .
Payment received by Cheque/Credit/Debit Card vide collection No:1173016112

Note :- This Certificate must be surrendred 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.

For Star Health and Allied Insurance Company Ltd.

Authorised Signatory

Entered By : PREMIA This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

Authorised Signatory
4 of 4