Family Accident Care Insurance Policy

Unique Identification No. SHAHLIP21042V012021

Policy Schedule
Policy No. : P/121514/02/2023/002376 Previous Policy No. :
Customer Code : AA0027503433 GSTIN : 33AAJCS4517L1Z5
Customer Name : Prakasam P SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 30933415 Issuing Office Code : 121514
Proposer Name : Prakasam P Issuing Office Name : Branch Office - Namakkal
Address : S/o Perumal .K ,23A North kadu, Address : Andhavar Plaza,No.609/B, II Floor,
Eswaramurthipalayam,Rasipuram. 609 / B,Salem Main Road,
Namakkal 637001.
Karungalpatti,Salem,Tamil Nadu -636202

Tel/Mobile : /8838022127/ Tel/Mobile : 04286 - 277677

E-mail id : pettaistarhealth@gmail.com E-mail id : namakkal@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 30/08/2022 Fulfiller Code : SH65468
Date of Inception of first policy : 30-AUG-2022
Intermediary Code : BA0000617449
Renewal Year : NEW
Collection Number & : 1181006470 & 30/08/2022 Name : M VENKATESH
Date
Premium : Rs 3750 /- Tel/Mobile : 9629777731/9629777731
CGST @9% : Rs 338 /- SGST / UTGST @9% : Rs 338 /-
Total Premium : Rs 4426 /- Stamp Duty : Re 250 /- E-mail id : licvenkatesh2020@gmail.com

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

Period of insurance : From : 30/08/2022 20:19 To : Midnight of 29/08/2023

Basic Floater Sum Insured : Rs. 50,00,000 /- Scheme Description : 1A+2C
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 Prakasam P M 10/07/1981 41 SELF 30933415-1 No PED declared 30/08/2022
2 P . Sowmiyaa F 04/04/2003 19 DEPENDANT 30933415-2 No PED declared 30/08/2022
CHILD
3 P . Vishal M 27/06/2006 16 DEPENDANT 30933415-3 No PED declared 30/08/2022
CHILD

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 P Sowmiyaa Daughter 19 100

Entered By : STAR_PORTAL 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 :Tue Aug 30 20:18:56 IST 2022
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/121514/02/2023/002376

Sector Classification

Rural

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.398 DATED.10th November 2021"
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Namakkal on 30th
Day of August 2022.

Entered By : STAR_PORTAL 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. : 33E181Y23P001352 Customer ID : AA0027503433

Invoice Date : 30/08/22 Policy No : P/121514/02/2023/002376
Recipient Supplier

GSTIN : - GSTIN : 33AAJCS4517L1Z5

Proposer Name : Prakasam P NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Namakkal
Address : S/o Perumal .K ,23A North kadu, Tel/Mobile : Andhavar Plaza,No.609/B, II Floor,
Eswaramurthipalayam,Rasipuram. 609 / B,Salem Main Road,
Namakkal 637001.
City : City : NAMAKKAL
State : Tamil Nadu State : Tamil Nadu
Pincode : 636202 Pincode : 637001
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.

E. & O.E
This is a digitally signed document and hence no physical signature is required

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

Entered By : STAR_PORTAL 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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