Branch Office - Goregaon 2nd Floor, North Nalanda Samant Compound Near Sai Veg World Restaurant , Opp.

Goregaon
Railway Station Goregaon E Mumbai 400063. , , GOREGAON , 400063
Collection Receipt
Customer Code : AA0005486049

Received from : Mr.AMAR SHIVAJI CHITKATE

Customer Address : ROOM NO.03, GRD FLOOR, NARMADA NIWAS WORLI Collection No : 11-01/1274009463

KOLIWADA MUMBAI-400030 Collection Date : 02/09/2022

- Office Code : 171119 - Branch Office - Goregaon

Supplier GSTIN : 27AAJCS4517L1ZY

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

Amount Collected : Rs. 8399 /- Inclusive of tax :

Amount in words : Indian Rupees Eight Thousand Three Hundred Ninety-Nine Only

Towards the Following : PREMIUM RECEIPT Mr.AMAR SHIVAJI CHITKATE

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/171119/01/2023/009598 SH11572 BA0000151856 8399 CHQ Bank of Maharashtra 196825 02/09/2022

(BOM)

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

IRDA Regn. No 129 Corporate Identity Number L66010TN2005PLC056649 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@starhealth.in Website :www.starhealth.in IRDAI Regn.no: 129