ENDORSEMENT SCHEDULE

Family Health Optima Insurance Plan

SHAHLIP22030V062122
Policy No : P/161130/01/2022/138988 Endorsement No : P/161130/01/2022/138988/001

Policy Period : 30-JAN-22 To 29-JAN-23 Endorsement Date : 04/02/2022

GSTIN : 06AAJCS4517L1Z2

SAC Code : 997133/Accident and Health Insurance Services

Proposer Code : 26535762 Issuing Office Code : 161130

Proposer Name : Ravindra manohar jawanjal Issuing Office Name : Branch Office - Gurgaon III

Address : Ram nagar Address : 412/2, K - I Tower,

mehkar M G Road, Sector 14,
Mehkar (M Cl),Buldana,Maharashtra-443301
Gurgaon, Haryana

Tel/Mobile : /7757868742/ Tel/Mobile : 0124-4797452

Email id : jawanjalRavindra@gmail.com Email id : gurgaon3@starhealth.in

Proposer GSTIN : - Place of Supply : -

Collection No : Fulfiller Code : SO161130

Collection Date :
Intermediary Code : LC0000000619
Premium: Rs.0/- IGST @18% : 0 /-
Name : M/S.POLICYBAZAAR INSURANCE
CGST @9% : SGST / UTGST @9% : /-
Kerala Flood Cess@1%: Rs./-
BROKERS PRIVATE LIMITED
Total Premium: Rs.0/- Phone : 1800-258-5970/9971552250

Email_id : care@policybazaar.com
Endorsement Effective : From 19:12 On 04/02/2022 To Midnight Of 29/01/2023

Type of Endorsement : Change in Risk Element

Description :

It is hereby agreed and declared that the date of birth of the insured person(s) covered under this policy shall be read as mentioned hereunder and not as
stated in the schedule of the policy. Insured Name: Ashwini Ravindra Jawanjal Date of Birth (DD/MM/YYY): 06/10/1998

"All other terms and conditions remains unaltered".

Warranted that in case of dishonour of premium cheque(s) the within mentioned policy stands cancelled from inception and the company absolves all liabilities under the
Policy/Endorsement.
In witness whereof the undersigned being authorised by and on behalf of the company has herein to set his hand at Branch Office - Gurgaon III on 05th Day of February 2022.

Entered By : SH24603 Approved By : SH26511

Place : Gurgaon For and on behalf of

Date : 04/02/2022 Star Health And Allied Insurance Co Ltd

IRDA Regn. No 129

Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
Authorised Signatory