ACCIDENT CARE INDIVIDUAL INSURANCE POLICY

Unique Identification No:IRDAI/HLT/SHAI/P-P/V.III/134/2017-18

Schedule
Policy No. : P/161118/02/2021/000548 Previous Policy No. :
Customer Code : AA0015834937 GSTIN : 07AAJCS4517L1Z0
Customer Name : NITIN VASHISHT SAC CODE : 997133/Accident and Health Insurance Services
Proposer's Code 18826216 Issuing Office Code : 161118
:
Issuing Office Name : Branch Office - Janak Puri
Proposer Name : NITIN VASHISHT
Issuing Office Address : C-2, Third Floor, New Krishna Park
Address : 94, RAMPURA,
Vikas Puri, Near Janakpuri West Metro
REWARI Station
Janakpuri
Rewari,Rewari,Haryana-123401
Tel/Mobile : /7065352543/ Tel/Mobile : 011 - 46763300 - 14
Email id : accounts@sun-photonics.com Email id : janakpuri@starhealth.in
Proposer GSTIN : - Place of Supply : -
Date of Inception of first policy : 10-NOV-2020 Fulfiller Code : SH24830
Renewal Year : NEW :
Intermediary Code BA0000038971
Collection Number : 1172025860
Name : RAKESH KUMAR
Collection Date : 10/11/2020
Premium : Rs.825 /-
Phone : 9968375770/9968375770
Email id : raakesh077@gmail.com
IGST @18% : Rs.149 /-
Stamp Duty : Rs . 30 /- Total Premium : Rs . 974 /-
Total Premium In Words : Indian Rupees Nine Hundred Seventy Four Only
Period of Insurance : From 10/11/2020 11:18 To Midnight Of 09/11/2021
Total Sum Insured : Rs . 600000 /-
In words : Rupees Six Lakhs Only.

Insured Details :
Sl. Name of the Insured Gender DOB Age Relation with Occupation Risk Group Pre- Cumulative Inception
No in yrs proposer existing Bonus Rs. Date
Disabilities
1 NITIN VASHISHT M 10/10/1988 32 SELF SERVICE Risk Group I 0 0 10-NOV-20

Coverage Details :

Sl. Sum Insured (Rs.) Optional Benefits opted

No Name of the Insured Table A Table B Table C Total Medical Hospital Home Winter
Expenses Cash Convalescence Sports
Extension
1 NITIN VASHISHT 0 0 600000 600000 Yes No No No

Entered by : PORTAL Approved by : PORTAL

For Star Health and Allied Insurance Company Ltd.

Place : JANAK PURI
:

Authorised Signatory

IRDAI Regn. No 129 CN=R Margabandhu,

R Margabandhu
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b154
75488cdf3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,
Corporate Identity Number U66010TN2005PLC056649 OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806c
a65f89e15179f5fe50a, OU=UNDERWRITING - Chief Risk Officer,
O=STAR HEALTH AND ALLIED INSURANCE COMPANY, C=IN.
Date :Tue Nov 10 11:18:00 IST 2020 1 of 3
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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
Attached to and forming part of Policy No: P/161118/02/2021/000548

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 NIKITA VASHISHT Spouse 32 100

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(s) 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 ab-initio
(from inception).
General Condition No. 2 regarding Claims Settlement shall read as follows and not as stated in policy wordings:
"The Company shall pay interest as per Insurance Regulatory and Development Authority of India (Protection of Policyholders' Interests)
Regulations, 2017, in case of delay in payment of an admitted claim under the Policy"

THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED.

Important
Intimation about an event or occurrence that may give rise to a claim under this policy must be given within 30 days of its happening. Toll Free No:
1800 425 2255/1800 102 4477 Email: support@starhealth.in Fax No: 1800 425 5522

NOTE : Kindly note that the settlement of claims under the Policy are subject to the provisions of Anti- Money Laundering / Counter
Financing of Terrorism (AML/CFT) policy of the Company. For further details, please visit our website www.starhealth.in
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Janak Puri on 10th
Day of November 2020.

Entered by : PORTAL Approved by : PORTAL

For Star Health and Allied Insurance Company Ltd.

Place : JANAK PURI
:

Authorised Signatory

2 of 3

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
 TAX Invoice

Invoice No. : 7H172Y21P0000865 Customer ID : AA0015834937

Invoice Date : 10/11/20 Policy No : P/161118/02/2021/000548
Recipient Supplier

GSTIN : - GSTIN : 07AAJCS4517L1Z0

Proposer Name : NITIN VASHISHT NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Janak Puri
Address : 94, RAMPURA, Issuing Office : C-2, Third Floor, New Krishna Park
REWARI Address Vikas Puri, Near Janakpuri West Metro
Station
Janakpuri
City : Rewari,Rewari,Haryana-123401 City : JANAK PURI
State : Haryana State : Delhi
Pincode : 123401 Pincode : 110018
Client Category : IND Place of Supply : 7 - Delhi

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 G=C*Cess H=C+D+E+F+G
Code
*CGST *UTGST or
SGST
997133 Insurance 825 0 825 149 Rs. 974
Services
Total Invoice Value (in Figures) : Rs. 974
Total Invoice Value (in Words) : Rupees: Nine hundred seventy-
four 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

IRDAI Regn. No 129 Corporate Identity Number U66010TN2005PLC056649 Email ID : stargst@starhealth.in

Entered by : PORTAL Approved by : PORTAL

For Star Health and Allied Insurance Company Ltd.

Place : JANAK PURI
:

Authorised Signatory

3 of 3

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