IMPORTANT

11/03/2022
To,

SANDEEP KUMAR NIKHIL,

H-20 Nutan pally Bhiringhi durgapur
DURGAPUR

Durgapur (M Corp.),Barddhaman,West Bengal -713213

Mobile : 7061873199.

Dear Customer,

Re: Health Insurance Policy - P/191114/01/2022/022710

We are extremely thankful for availing health insurance from us and we enclose the policy along with the terms and
conditions.

The said policy has been prepared based on the details furnished by you in the proposal form (copy enclosed) and
the medical reports, wherever applicable. We shall thank you if you can verify the policy to ensure that all the details
are incorporated correctly as per the proposal. In case of any discrepancy noticed, please communicate the same to
us immediately. You will appreciate that it is the primary duty of the proposer to fill the proposal form and also to
make sure that the proposal contains all the details correctly so also the policy has incorporated the details correctly.

This insurance policy is subject to various exclusions including exclusion for pre-existing diseases and conditions in
this policy. If there is suppression of any material fact in the proposal, the contract shall become null and void ab
initio.

We would like to mention that we have incorporated the name of the intermediary as indicated by you in the proposal
who will be of assistance to you.

The policy is subject to the condition of "free look period". As per this condition, a free look period of 15 days from
the date of receipt of the policy is available to you to review the terms and conditions of the policy. In case you are
not satisfied with the terms and conditions, you may seek cancellation of the policy and in such an event, we shall
allow refund of premium paid after adjusting the cost of pre-acceptance medical screening, if any, stamp duty
charges, and proportionate risk premium for the period on cover, provided no claim has been made until such
cancellation.
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,

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 Mar 11 20:54:07 IST 2022

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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
 Family Health Optima Insurance Plan
SHAHLIP22030V062122
Policy No. : P/191114/01/2022/022710 Previous Policy No. :
Customer Code : AA0024450776 GSTIN : 19AAJCS4517L1ZV
Customer Name : SANDEEP KUMAR NIKHIL SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 27779171 Issuing Office Code : 191114
Proposer Name : SANDEEP KUMAR NIKHIL Issuing Office Name : Branch Office - Durgapur
Address : H-20 Nutan pally Bhiringhi durgapur Address : SM-10, Ambedkar Sarani,City
DURGAPUR Centre,Durgapur - 713 216.

Durgapur (M
Corp.),Barddhaman,West Bengal-
713213
Tel/Mobile : /7061873199/ Tel/Mobile : 0343 - 2546041 / 42 / 44 / 45
E-mail id : nikhilsandeep2009@gmail.com E-mail id : durgapur@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 11/03/2022 Fulfiller Code : SH6622
Date of Inception of first policy : 11-MAR-2022
Intermediary Code : BA0000062401
Renewal Year : NEW
Collection Number & : 1146024231 & 11/03/2022 Name : SANTOSH KUMAR AGARWAL
Date
Premium : Rs 10900 /- Tel/Mobile : /9333901810
CGST @9% : Rs 981 /- SGST / UTGST @9% : Rs 981 /-
Total Premium : Rs 12862 /- Stamp Duty : Re 1 /- E-mail id : santoshagarwal.dgp@gmail.com

Total Premium In Words : Rupees Twelve Thousand Eight Hundred Sixty Two Only
Installment Facility Optn :No Premium Payment Frequency :Annual Installment Amount Rs. : 0

Period of insurance : From : 11/03/2022 20:54 To : Midnight of 10/03/2023

Basic Floater Sum Insured : 300000
In words : Rupees: Three Lakhs Only
Bonus: Rs. 0 Limit of Coverage : Rs. 300000 Recharge Benefit : Rs. 75000
Scheme Description : 2ADULT+2CHILD
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 SANDEEP KUMAR M 15/10/1983 38 SELF 27779171-1 No PED declared 11/03/2022
NIKHIL
2 RUBY KUMARI F 05/02/1992 30 SPOUSE 27779171-2 No PED declared 11/03/2022
SHRIVASTVA
3 AARUSH NIKHIL M 08/05/2017 4 DEPENDANT 27779171-3 No PED declared 11/03/2022
CHILD
4 SAANVI NIKHIL F 01/05/2020 1 DEPENDANT 27779171-4 No PED declared 11/03/2022
CHILD

Entered By : STAR_PORTAL For Star Health and Allied Insurance Company Ltd.
Approved By : PORTAL

Authorised Signatory

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

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 Attached to and forming part of Policy No. P/191114/01/2022/022710
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 RUBY KUMARI Spouse 30 100

SHRIVASTVA

Sector Classification

Urban

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.
"This policy covers 68 other excluded expenses. Accordingly, exclusion (Code Excl 37) appearing in the policy wordings stands
deleted"

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 .
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Durgapur on 11th
Day of March 2022.

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

Entered By : STAR_PORTAL For Star Health and Allied Insurance Company Ltd.
Approved By : PORTAL

Authorised Signatory

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

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 Star Health and Allied Insurance
Emergency Help Line No. 1800 425 2255 / 1800 102 4477 Company Limited
e-mail : support@starhealth.in Website : www.starhealth.in Customer Identity Card
Please quote the Customer Id No. for assistance
Customer ID No. : 27779171-1
This Card is valid until otherwise Cancelled.
Name : SANDEEP KUMAR NIKHIL
This ID Card is invalid, if the insurance cover is not in force.
Immediate intimation to 'Star' through above Tel Nos. is a must Date Of Birth : 15-OCT-83 Age : 38 Years
in case of Hospitalisation. Gender : Male Office Code : 191114
At the time of hospitalization, kindly submit any Government Valid From : 11-MAR-22 TA/SSM/SM Code : SH6622
approved photo ID Card.
Agent/Broker/TE Code : BA0000062401
Corporate
For Free Identity
Medical AdviceNumber:
Call U66010TN2005PLC056649 IRDAI Regn. No:129

Star Health and Allied Insurance Star Health and Allied Insurance
Company Limited Company Limited

Customer Identity Card Customer Identity Card

Customer ID No. : 27779171-2 Customer ID No. : 27779171-3

Name : RUBY KUMARI SHRIVASTVA Name : AARUSH NIKHIL
Date Of Birth : 05-FEB-92 Age : 30 Years Date Of Birth : 08-MAY-17 Age : 4 Years
Gender : Female Office Code : 191114 Gender : Male Office Code : 191114
Valid From : 11-MAR-22 TA/SSM/SM Code : SH6622 Valid From : 11-MAR-22TA/SSM/SM Code : SH6622
Agent/Broker/TE Code : BA0000062401 Agent/Broker/TE Code : BA0000062401
IRDAI Regn. No:129 IRDAI Regn. No:129

Star Health and Allied Insurance

Company Limited
Customer Identity Card

Customer ID No. : 27779171-4

Name : SAANVI NIKHIL
Date Of Birth : 01-MAY-20 Age : 1 Years
Gender : Female Office Code : 191114
Valid From : 11-MAR-22TA/SSM/SM Code : SH6622
Agent/Broker/TE Code : BA0000062401
IRDAI Regn. No:129

*This is a temporary ID card issued along with the policy. Original ID cards will be dispatched shortly.

Entered By : STAR_PORTAL For Star Health and Allied Insurance Company Ltd.
Approved By : PORTAL

Authorised Signatory

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

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 TAX Invoice

Invoice No. : 19L146Y22P000934 Customer ID : AA0024450776

Invoice Date : 11/03/22 Policy No : P/191114/01/2022/022710
Recipient Supplier

GSTIN : - GSTIN : 19AAJCS4517L1ZV

Proposer Name : SANDEEP KUMAR NIKHIL NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Durgapur
Address : H-20 Nutan pally Bhiringhi durgapur Tel/Mobile : SM-10, Ambedkar Sarani,City
DURGAPUR Centre,Durgapur - 713 216.

City : Durgapur (M City : DURGAPUR

Corp.),Barddhaman,West Bengal-
713213
State : West Bengal State : West Bengal
Pincode : 713213 Pincode : 713 216
Client Category : IND Place of Supply : 19 - West Bengal

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

997133 Insurance Services 10900 0 10900 981 981 Rs. 12862

Total Invoice Value (in Figures) : Rs. 12862
Total Invoice Value (in Words) : Rupees: Twelve thousand eight
hundred sixty-two 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

Corporate Identity Number U66010TN2005PLC056649 Email ID : stargst@starhealth.in

Entered By : STAR_PORTAL For Star Health and Allied Insurance Company Ltd.
Approved By : PORTAL

Authorised Signatory

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

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 Name Of the Product Family Health Optima Insurance plan

Product UIN No. SHAHLIP22030V062122

Summary of Important Benefits
Refer to
S.No Particulars of Coverage / Benefits Benefit Limits (in Rs.) Policy
clause No.

Sum Insured (in Rs.) 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000

Room Rent (Per Day) - Up to

1 *Hospitalization expenses will be considered in 2,000 2,000 5,000 5,000 Single Standard A/C Room 2(A)
proportion to the eligible Room Rent
Surgeon, Anesthetist, Medical Practitioner,
2 Actual 2(B)
Consultants, Specialist Fees

3 Anesthesia, Blood,Oxygen,Operation theatre Actual 2(C)

charges, ICU charges, Medicines and Drugs

Limit Per Eye (Up to) 12,000 12,000 25,000 30,000 40,000 50,000 50,000 50,000 50,000
4 Cataract treatment 2(E)
Limit Per policy period (Up to) 12,000 12,000 35,000 45,000 60,000 75,000 75,000 75,000 75,000

Limit Per hospitalization 750 750 750 750 750 750 750 750 750
5 Emergency Ambulance 2(F)
Limit Per policy period 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500

6 Air Ambulance N/A N/A N/A N/A Covered up to 10% of the Sum Insured per policy period 2(G)

7 Pre-Hospitalization 60 days 60 days 60 days 60 days 60 days 60 days 60 days 60 days 60 days 2(H)

8 Post-Hospitalization 90 days 90 days 90 days 90 days 90 days 90 days 90 days 90 days 90 days 2(I)

9 All Day Care Procedures 2(D)

Day Care Treatments / Procedures
10 Coverage for a period exceeding three days 2(J)
Domiciliary Hospitalization
11 10% of the Sum insured or Rs.1,00,000/- whichever is less 2(K)
Organ Donor Expenses (per policy period)
12 Cost of Health Checkup (Available after every claim N/A N/A 750 1,000 1,500 2,000 2,500 3,000 3,500 2(L)
free year) Up to
10% of the Sum Insured or maximum of Rs.50,000/- whichever is less in a policy year (Available 2(M)
13 Coverage for New Born Baby if the mother is covered under the policy for a continuous period of 12 months)
14 Emergency Domestic Medical Evacuation 2(N)
5,000 5,000 5,000 5,000 7,500 7,500 7,500 10,000 10,000
(Per Hospitalization) Up to
15 N/A N/A N/A N/A N/A 5,000 5,000 5,000 5,000 2(O)
Compassionate Travel Up to
16 5,000 5,000 5,000 5,000 5,000 5,000 5,000 5,000 5,000 2(P)
Repatriation of Mortal Remains (Per Policy Period)
17 Treatment in Valuable Service Provider (Lump- 1% of the Sum Insured subject to a maximum of Rs.5,000/- is payable as lumpsum per policy
Sum benefit) period 2(Q)

18 N/A N/A 800 800 800 800 800 1,000 1,000 2(R)
Shared Accommodation ( BenefitAmount Per Day)
AYUSH Treatment (Ayurveda, Unani, siddha and
19 10,000 10,000 10,000 10,000 15,000 15,000 15,000 20,000 20,000 2(S)
Homeopathy Systems of medicines) Up to

Available from a Doctor in the Company's network of medical practitioners,Mail:"e_medicalopinion@ 2(T)

20 starhealth.in"
Second Medical Opinion

21 Assisted Reproduction Treatment (Limit for every N/A N/A N/A N/A 1,00,000 2,00,000 2,00,000 2,00,000 2,00,000 2(U)
block of 36 months and payable on renewal)

N/A N/A Available for three times per policy period and 100% of the Sum Insured at 2 (V)
22 Automatic Restoration of Sum Insured each time

23 Recharge Benefit N/A N/A 75,000 1,00,000 1,50,000 1,50,000 1,50,000 1,50,000 1,50,000 2(W)

Additional Sum Insured for Road Traffic Accident

24 (Once in a Policy Period) 25% of the Sum Insured subject to a maximum of 5,00,000 2(X)

25 BONUS The insured is entitled to Bonus of 25%of expiring Basic Sum Insured and 2(Z)
N/A N/A additional 10%of the expiring Sum Insured in the subsequent years

Entered By : STAR_PORTAL For Star Health and Allied Insurance Company Ltd.
Approved By : PORTAL

Authorised Signatory

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

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 Co-Payment The Policy is subject to 20% Co-Pay for each and every claim for person whose age at the time of 2(AA)
26
entry is 61 years and above

27 Coverage for Modern Treatement Covered up to the limits mentioned in the policy clause 2(Y)

28 Installment facility (if Opted) Available 4(13)

N/A = Benefits not available to the respective Sum Insured.

Note: The above information is only indicative. For complete details of the Terms & Conditions kindly read the policy wordings attached.

Entered By : STAR_PORTAL For Star Health and Allied Insurance Company Ltd.
Approved By : PORTAL

Authorised Signatory

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

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