Branch Office - Yamunanagar 2nd Floor, SCO 184-185, Commercial Belts, Sector 17 , Huda Jagadhri, Near New Grain

Market,
, Yamuna Nagar-135003 , , 135003
Collection Receipt
Customer Code : AA0017355269

Received from : Shiv kumar

Customer Address : # 345 krishna colony Collection No : 11-01/1293013669

Old hamida YAMUNANAGAR Collection Date : 19/02/2021

Office Code : 211120 - Branch Office - Yamunanagar

Supplier GSTIN : 06AAJCS4517L1Z2

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

Amount Collected : Rs. 26738 /- Inclusive of tax :

Amount in words : Indian Rupees Twenty-Six Thousand Seven Hundred Thirty-Eight Only

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/211120/01/2021/027555 SH36311 BA0000327047 26738 CC EMI 12329346885 19/02/2021

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

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