Family Accident Care Insurance Policy

Unique Identification No. SHAHLIP21042V012021

Policy Schedule

In consideration of payment of Rs.4426 /- towards renewal premium of Policy number: P/121300/02/2022/001234, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No : P/121300/02/2023/001180

GSTIN : 33AAJCS4517L1Z5
Customer Code : AA0017818514
Customer Name : Mr.R. VALLUVAN SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 20907902 Issuing Office Code : 121300
Proposer Name : Mr.R. VALLUVAN Issuing Office Name : Zonal Office - Madurai
Address : J12, POTHIGAI STREET, Address : No.10, Deputy Collectors Colony,
KUZHANTHAI SAMY NAGAR, K.K.Nagar,
VANDIYUR, ANNA NAGAR, Madurai
MADURAI
Madurai,Madurai,Tamil Nadu -625020
Tel/Mobile : -/9976272252/ Tel/Mobile : 0452-4231535
E-mail id : samep33@yahoo.in E-mail id : madurai.ao@starhealth.in,madurai.zo@starh
ealth.in
Proposer GSTIN : - Place of Supply : Tamil Nadu / State Code : 33
Proposal date : 21/03/2021 Fulfiller Code : SH3896
Date of Inception of first policy : 21-MAR-2021
Intermediary Code : BA0000372432
Renewal Year : Second Year
Collection Number & : 1018008416 & 15/02/2023 Name : Mr.R VALLUVAN
Date
Premium : Rs 3750 /- Tel/Mobile : 9976272252/9976272252
CGST @9% : Rs 338 /- SGST / UTGST @9% : Rs 338 /-
Total Premium : Rs 4426 /- Stamp Duty : Re 250 /- E-mail id : samep33@yahoo.in

Total Premium In Words : Rupees Four Thousand Four Hundred Twenty Six Only

Period of insurance : From : 21/03/2023 00:00 To : Midnight of 20/03/2024

Basic Floater Sum Insured : Rs. 50,00,000 /- Scheme Description : 2A+1C
In words : Rupees: Fifty Lakhs Only
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 R. VALLUVAN M 31/12/1973 49 SELF 20907902-1 No PED declared 21/03/2021
2 N. SELVA PRIYA F 04/06/1978 44 SPOUSE 20907902-2 No PED declared 21/03/2021
3 T.R.V. KARTHI M 02/11/2003 19 DEPENDANT 20907902-3 No PED declared 21/03/2021
CHILD

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

L66010TN2005PLC056649 Authorised Signatory

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 :Wed Feb 15 18:09:30 IST 2023
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@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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 Attached to and forming part of Policy No. P/121300/02/2023/001180
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 N. SELVA PRIYA Spouse 44 100

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 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.
Toll Free No : 1800 425 2255 / 1800 102 4477 Email: support@starhealth.in, Fax No: 1800 425 5522 .

"CONSOLIDATED STAMP DUTY PAID VIDE G.O.(RT) NO.402 DATED.15TH SEP 2022"

It is hereby made clear that all terms, conditions, clauses, warranties, exclusions etc., as already issued, forming part of the policy of
insurance originally issued at the time of inception of this relationship, shall continue to be operative and unaltered, forming part of this
renewal insurance cover also.

Reference may be made to those terms, conditions etc., for identifying the scope/extent of coverage.

Other excluded expenses as detailed in our website "www.starhealth.in"

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Zonal Office - Madurai on 15th Day
of February 2023.

Entered By : PREMIA For Star Health and Allied Insurance Company Ltd.
: 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 : L66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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 TAX Invoice

Invoice No. : 33K018Y23P000609 Customer ID : AA0017818514

Invoice Date : 15/02/23 Policy No : P/121300/02/2023/001180
Recipient Supplier

GSTIN : - GSTIN : 33AAJCS4517L1Z5

Proposer Name : Mr.R. VALLUVAN NAME : Star Health and Allied Insurance Co Ltd
- Zonal Office - Madurai
Address : J12, POTHIGAI STREET, Tel/Mobile : No.10, Deputy Collectors Colony,
KUZHANTHAI SAMY NAGAR, K.K.Nagar,
VANDIYUR, ANNA NAGAR, Madurai
MADURAI
City : City : MADURAI
State : Tamil Nadu State : Tamil Nadu
Pincode : 625020 Pincode : 625020
Client Category : IND Place of Supply : 33 - Tamil Nadu

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 3750 0 3750 338 338 Rs. 4426

Total Invoice Value (in Figures) : Rs. 4426
Total Invoice Value (in Words) : Rupees: Four thousand four
hundred twenty-six 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.

I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is
more than the aggregate turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in
terms of the provisions of the said sub-rule.
E. & O.E
This is a digitally signed document and hence no physical signature is required

Entered By : PREMIA For Star Health and Allied Insurance Company Ltd.
: 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 : L66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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 Corporate Identity Number L66010TN2005PLC056649 Email ID : stargst@starhealth.in

Entered By : PREMIA For Star Health and Allied Insurance Company Ltd.
: 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 : L66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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