Star Health And Allied Insurance Company Limited

No. 95,Vaigarai Block, I Floor St. Paul's Complex,(Opp. to Head

Post Office) Bharathiyar Salai
Tiruchirappalli Town Tamil Nadu-620001
Phone: 0431-2461324 Telefax:

Collection Receipt

Customer Code : 12788868 Collection No : 11-01/1016009083

Received From : MRS.T.USHA Collection Date : 10-Jan-2024
Customer Address : No: 1-4, 5th crossThiru Nagar . Office Code : 121200 - Zonal Office - Trichy
Edumalai Road, GSTIN : 33AAJCS4517L1Z5
Mannachanallur .Trichy. Place of Supply : Tamil Nadu
Manachanallur Taluka Tamil
Nadu 621005
Customer mobile : ./890XXXXX73 Type of proposal
: Renewal
number
Customer GSTIN : NO State Code : 33
Amount Collected : Rs. 21,772/-
Amount in words : INDIAN RUPEES Twenty One thousand seven hundred seventy two only
Towards the Following : Amount Receipted towards Premium
Sr. Proposal Fulfiller Intermediary Amount Mode of Bank CHQ/CC/DD CHQ/DD/BC
No Ref. No Code Code Collected payment Name No Dt.
(Rs)
1 R/121200/01 SH0253 BA0000010875 21,772/- Cash
/2023/01443
6

For Star Health and Allied Insurance Co. Ltd.

Authorised Signatory

Note : Receipt Subjected to realization of Cheque/DD

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 payments of Premium: Cash, Cheque, DD, Net Banking, RTGS/NEFT, Credit Card, Debit
Card, UPI, Payment Gateway(PAYTM, PAYU, AIRPAY, BBPS, CSC, UBONA).”

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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