Star Health And Allied Insurance Company Limited

Pazhamudir Square 2nd floor, No. 39/3, T V Samy Road (East),

Opp. Post Office, R S Puram, Coimbatore 641002.
Coimbatore Tamil Nadu-641002
Phone: 0422-4200382 Telefax: 4200382

Collection Receipt

Customer Code : 20010872 Collection No : 181009021711

Received From : SATHISH J Collection Date : 23-Jan-2023
Customer Address : S/o. Jaganathan 4/182-3 Office Code : 120000 - Zonal Office -
Kuruchandra Avenue, Railway Coimbatore
feeder road, GSTIN : 33AAJCS4517L1Z5
Muthugoundanpudur, Place of Supply : Tamil Nadu
Coimbatore
Sulur Taluka Tamil Nadu
641402
Customer GSTIN : NO State Code : 33
Amount Collected : Rs. 12,664/-
Amount in words : INDIAN RUPEES Twelve thousand six hundred sixty four only
Towards the Following : Amount Receipted towards Premium
Sr. Proposal Fulfiller Intermediary Amount Mode of Bank CHQ/CC/DD CHQ/DD/BC
No Ref. No Code Code Collected payment Name No Dt.
(Rs)
1 61230251356 SH58272 BA0000555862 12,664/- Payment Legacy 16649279976 23-Jan-2023
9 Gateway Bank
Branch

For Star Health and Allied Insurance Co. Ltd.

Authorised Signatory

Note : Receipt Subjected 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.

CN=R Margabandhu, SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b15475488cdf3b2c3c26c3c9,

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

OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806ca65f89e15179f5fe50a, OU=UNDERWRITING - Chief
Risk Officer, O=STAR HEALTH AND ALLIED INSURANCE COMPANY, C=IN. Date :Mon Jan 23 06:59:17 IST 2023
Page 1 of 1
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