Star Health And Allied Insurance Company Limited

Date : 11-Nov-2021
To, IMPORTANT

Mr. MR.S.PUTHU RAJA ,

No.110, Old No.55
Bharathiyar Street
VILLUPURAM-605602
Villuppuram Taluka,Tamil Nadu-605602
Mobile : 9942981111

Dear Customer,

Re: Health Insurance Policy - 11220003364210

We are extremely thankful to you for your renewal instructions and payment of premium. We enclose the
renewed policy based on our records. We would request you to kindly study the renewed policy carefully and
revert to us if there is any discrepancy to enable us to attend to the same.

Kindly note that the above request is very important and if we do not hear anything from you within
15 days, we would presume that the policy issued by us is in order and the contract is concluded.

We would like to mention that we have incorporated the name of the intermediary as indicated by you.

We wish you good health and we look forward to serve you in the days to come.

With kind regards,

Authorised Signatory

In case of a need for hospitalization, kindly prefer our network hospital (list is available in our website) for a
quick response to your claim request.
Please select the room as per your eligibility stipulated in your policy to avoid additional payment
from your pocket towards the proportionate increase which would invariably be charged by the
hospital for the higher room category occupied.
Sum Insured of this Policy is meant for utilization till its expiry.Bearing this aspect in mind,we have no
doubt,you will choose appropriate hospital,room rent and treatment charges etc.

Should you need any assistance, our customer care will be delighted to assist you ,whose toll free no. is
1800-425-2255/1800-102-4477.

However,the ultimate decision will be that of yours only.

CN=R Margabandhu,
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b15475488cdf

R Margabandhu 3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,

OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806ca65f89e15
179f5fe50a, OU=UNDERWRITING - Chief Risk Officer, O=STAR HEALTH AND
ALLIED INSURANCE COMPANY, C=IN. Date :Thu Nov 11 16:06:31 IST 2021
Page 1 of 5

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
 Star Health And Allied Insurance Company Limited

Family Health Optima Insurance Plan

Unique Identification No. SHAHLIP22030V062122
POLICY SCHEDULE
Policy No. : 11220003364210 Previous Policy No : P/111211/01/2021/003908
Customer Code : 4753455 GSTIN : 33AAJCS4517L1Z5
Customer Name : Mr. MR.S.PUTHU RAJA SAC Code : 997133 / Accident and Health
Insurance Services
Proposer Code : 4753455 Issuing Office Code : 111211
Proposer Name : Mr. MR.S.PUTHU RAJA Issuing Office Name : Branch Office - Villupuram
Proposer Address : No.110, Old No.55 Issuing Office Address : No.20/B, Pandit Jawaharlal
Bharathiyar Street Nehruji Road, Near Aswini
VILLUPURAM-605602 Hospital,
Villuppuram Taluka Tamil Nadu (Opp) Indian Bank,
605602 Villupuram - 605 602.

Villuppuram Town Tamil Nadu

605602
Phone No : 9942981111 Phone No : 04146-225091
E-mail Id : puthuraja@yahoo.com E-mail Id : villupuram@starhealth.in
Proposer GSTIN : NO Place of Supply : Tamil Nadu
Proposal date : 22-Sep-2011 Fulfiller Code : SO111211
Date of Inception : 22-Sep-2011
of first policy
Policy Category : Tenth Year Intermediary : BA0000237419
Collection No : 171067003883
Code
Collection Date : 11-Nov-2021 Name : Mr.SYEDZACRUDEEN
Premium : Rs. 11,950/-

CGST @ 9% : Rs. 1,076/-

Phone No :9943050186/994305018
6
:
SGST @ 9% Rs. 1,076/-
E-mail Id : vhplan@gmail.com
Total Premium : Rs. 14,102/-
Stamp Duty : Re. 1/-

Total Premium In Words : Rupees Fourteen thousand one hundred two only
PERIOD OF INSURANCE : From : 17-Nov-2021 00:00 To : Midnight Of 16-Nov-2022
Installment Facility Option:No Premium Payment Frequency :Annual Installment Amount Rs. : 0/-

Basic Floater Sum Insured : Rs. 5,00,000/- Scheme Description : 2A+1C

In Words : Rupees Five lakhs only
Bonus : Rs. 2,75,000/- Limit of Coverage : Rs. 7,75,000/- Recharge Benefit : Rs. 1,50,000/-
Details of Insured Persons :
Sl. Age in Relationship Inception
Name of the Insured Gender Date of Birth ID Card No
no. Yrs with Proposer date
Mr. S.PUTHU RAJA
1 Male 13-Aug-1978 43 Self 1955363-1 22-Sep-2011

Pre Existing Disease : No PED Declared

Mrs. M.S.NEYA LANGTHASA
2 Female 01-Jan-1984 37 Spouse 1955363-2 22-Sep-2011

Pre Existing Disease : No PED Declared

Mr. S.P.MAHANT TEJA
3 Male 01-Nov-2010 11 Son 1955363-3 22-Sep-2011

Pre Existing Disease : No PED Declared

Entered by : CUSTPORTAL For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL
IRDA Regn.No.129

Corporate Identity Number U66010TN2005PLC056649

Authorised Signatory Page 2 of 5
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
 Star Health And Allied Insurance Company Limited

Attached to and forming part of Policy No: 11220003364210

Nominee Details:
Nominee Details for the Proposer Appointee Details
S.No Name Relationship Age % of the Appointee Name Appointee Relationship
with proposer claim Age with nominee

1 M S NEYA Spouse 37 100

LANGTHASA

Sector Classification:
Urban Unorganized Sector

''CONSOLIDATED STAMP DUTY PAID VIDE G.O.(RT) NO.231 DATED.12TH JULY 2021''

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.
Important
“This policy covers 68 other excluded expenses. Accordingly, exclusion (Code Excl 37) appearing in
the policy wordings stands deleted”
In the event of hospitalization of insured person, intimation should be given to the Company immediately,
however, within 24 hrs from the time of admission.
Toll Free No : 1800 425 2255 / 1800 102 4477 Email: support@starhealth.in, Fax No: 1800 425 5522.
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch
Office - Villupuram on 11th Day of November 2021.

Entered by : CUSTPORTAL For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL

Authorised Signatory Page 3 of 5

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
 Star Health And Allied Insurance Company Limited

Hospitalisation Benefit Policy

Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986

Policy No : 11220003364210 Type of Policy : Family Health Optima Insurance

Plan - 2021
Issue Office : 111211-Branch Office - Villupuram

Address : No.20/B, Pandit Jawaharlal Nehruji Road, Near Aswini Hospital,

(Opp) Indian Bank, Villupuram - 605 602.

Villuppuram Town Tamil Nadu 605602

Tel / Fax : 04146-225091

Email : villupuram@starhealth.in

This is to certify that Mr. MR.S.PUTHU RAJA has paid Rs 14,102/- (Total Premium : Indian Rupees
Fourteen thousand one hundred two only ) towards Premium for Hospitalization Insurance vide Policy No:
11220003364210 for the Period 17-Nov-2021 To 16-Nov-2022 issued on 11-Nov-2021.

Payment received by Payment Gateway vide Receipt No: 171067003883/1 Receipt Date: 11-Nov-2021

Note :- This Certificate must be surrendered to the Insurance Company for issuance of fresh Certificate in
case of Cancellation of the Policy or any alteration in the Insurance affecting the Premium.

Date : 11-Nov-2021 For and on behalf of

Place : Branch Office - Villupuram Star Health and Allied Insurance Company Ltd.

IRDA Regn.No.129

Corporate Identity Number U66010TN2005PLC056649 Authorised Signatory

Email ID: info@starhealth.in

Entered by : CUSTPORTAL For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL

Authorised Signatory Page 4 of 5

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
 Star Health And Allied Insurance Company Limited

Tax Invoice
Invoice No. : 332111I000214820 Customer ID : 4753455
Invoice Date : 11-Nov-2021 Policy No. : 11220003364210
Recipient Supplier
GSTIN : NO GSTIN : 33AAJCS4517L1Z5
Name : Mr. MR.S.PUTHU RAJA Name : Star Health and Allied Insurance Co Ltd -
Branch Office - Villupuram
Address : No.110, Old No.55 Address : No.20/B, Pandit Jawaharlal Nehruji Road, Near
Aswini Hospital,
Bharathiyar Street (Opp) Indian Bank, Villupuram - 605 602.
VILLUPURAM-605602
City : Villuppuram Pin Code : 605602 City : Villuppuram Pin Code : 605602
Taluka Town

State : Tamil Nadu Client : IND State : Tamil Nadu Place of : Tamil Nadu
Category supply

Taxable IGST @ UT/SGST @ CESS @ Total Invoice

Total Discount CGST @ 9%
Value 18% 9% 1% Value
HSN / SAC Description of
Code Service(s) F=C*
D=C* E=C* G= C * H=C+D+
A B C=A-B UTGST or
IGST CGST Cess E+ F + G
SGST

Insurance
997133 11,950.00 0 11,950.00 0 1,076.00 1,076.00 0 14,102.00
Services

Total Invoice Value (in Figures) : Rs. 14,102/-

Total Invoice Value (in Words) : Rupees Fourteen thousand one hundred two 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

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

Entered by : CUSTPORTAL For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL

Authorised Signatory Page 5 of 5

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