Branch Office - Jayanagar Shree Thulasi Towers,3rd floor, , No 672/43, 11 Main Road, , 4th Block, Jayanagar, Bangalore ,

BANGALORE , 560011
Collection Receipt
Customer Code : AA0006904433

Received from : Mr.NITESH.R

Customer Address : NO 703 2ND PHASE 1ST FLOOR DALAPATHI NILAYA Collection No : 11-01/1168028522
VIJAYANAGR 4TH STAGE - 570018,.
.,Mysore Collection Date : 08/11/2022

Karnataka-570018 Office Code : 141125 - Branch Office - Jayanagar

Mobile No : 77XXXXX800 Supplier GSTIN : 29AAJCS4517L1ZU

Customer GSTIN : Place of Supply : - State Code: 29

Amount Collected : Rs. 918 /- Inclusive of tax :

Amount in words : Indian Rupees Nine Hundred Eighteen Only Business Type : New Business

Towards the Following : PREMIUM RECEIPT INS

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 SH16727 BA0000193174 918 CCS 4712********496

9

Note : Receipt Subject to realization of Cheque / DD For Star Health and Allied Insurance Co. Ltd
This is only an evidence of receipt of money by the company
Risk will commence once the proposal is examined and accepted
Available modes of payment of Premium : Cash, Cheque, DD, Net Banking, RTGS/NEFT, Credit Card,
Debit card, UPI, Customer Portal and Star website. Authorised Signatory

CN=R Margabandhu,

R Margabandhu
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b15
475488cdf3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,
OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806
ca65f89e15179f5fe50a, OU=UNDERWRITING - Chief Risk Officer,
O=STAR HEALTH AND ALLIED INSURANCE COMPANY, C=IN.
Date :Tue Mar 14 15:51:21 IST 2023

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