Branch Office - Ghatkopar Room No: 110-111-112, Sanghvi Square, Opp: Bank of Baroda, , M. G.

Road, Ghatkopar (West),

Mumbai - 400 086. , , , 400 086
Advance Premium Receipt
Customer Code : AA0004798302 Receipt No : 27L173Y19R001111

Received from : VEMULA RAMESH BABU Receipt Date : 17/03/2019

Customer Address : V Ramesh babu, door no 6-44, Pathamajeru Collection No : 11-01/1173018302

Challapalli mandal krishna dist Collection Date : 17/03/2019

Office Code : 171116 - Branch Office - Ghatkopar

Supplier GSTIN : 27AAJCS4517L1ZY

Customer GSTIN : - Place of Supply : - State Code: -

Amount Collected : Rs. 19417 /- Inclusive of tax : IGST @18%- Rs. 2962/-

Amount in words : Indian Rupees Nineteen Thousand Four Hundred Seventeen Only SAC code : 997133

Towards the Following : PREMIUM RECEIPT ONLINE POLICY

S. No. Proposal Ref. No Fulfiller Code Intermediary Code Amount Collected Mode of Pay Bank Name CHQ/CC/DD No CHQ/DD/BC Dt

1 R/171116/01/2019/022296 SO171116 LC0000000351 19417 CC BANK 190317401861 17/03/2019

112870

For Star Health and Allied Insurance Co. Ltd

Note : Receipt Subject 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 Authorised Signatory

Amount of Tax Subject to reverse Charge : No

CN=SRINIVASAN RAMASWAMY,

SRINIVASAN SERIALNUMBER=91fa1f6086f94760c8858bf1d653fa94cf9b2caaf7d01
926c03552012536da26,
OID.2.5.4.20=b9b82e818a1c0f85a0f74b8e131a80293ef1084f20a913bd
c1f47ed182afbf8c, ST=Tamil Nadu, OID.2.5.4.17=600034, OU=CHIEF

RAMASWAMY FINANCIAL OFFICER, O=STAR HEALTH AND ALLIED INSURANCE

COMPANY LIMITED, C=IN. Date :Sun Mar 17 12:38:52 IST 2019

IRDA Regn. No 129 Corporate Identity Number U66010TN2005PLC056649 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