IMPORTANT

To,

SUDEB MONDAL,
C/O - MADHUSUDAN MONDAL ( NITYANANDA SARANI, P.O - BAMANGACHI, P.O -
BARASAT - 743248
.
.
Chandrapur (CT),North Twenty Four Parganas,West Bengal -743248
Mobile : 8276820306.

Dear Customer,

Re: Health Insurance Policy - P/191111/01/2019/010073

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 stay in eligible room as stated in the policy, to avoid
payment of proportionate increased charges claimed by the hospitals, from your hand.
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,

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 :Mon Nov 15 15:26:53 IST 2021

1 of 4

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
 MEDICLASSIC INSURANCE POLICY (INDIVIDUAL)
SCHEDULE
Unique Identification No.IRDA/NL-HLT/SHAI/P-H/V.II/400/13-14

In consideration of payment of Rs.3398/- towards renewal premium of Policy number: P/191111/01/2018/008348, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No : P/191111/01/2019/010073

Customer Code : AA0004233402 GSTIN : 19AAJCS4517L1ZV
Customer Name : Mr.SUDEB MONDAL SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 6122635 Issuing Office Code : 191111
Proposer's Name : SUDEB MONDAL Issuing Office Name : Branch Office - North Kolkata
Address : C/O - MADHUSUDAN MONDAL ( Address : First floor, 229/2, Acharya Prafulla
NITYANANDA SARANI, P.O - Chandra Road,
BAMANGACHI, P.O - BARASAT Kolkata - 700 004
- 743248
.
Phone No : 033 - 25302533 / 25302534
.
E-mail Id : northkolkata@starhealth.in
Chandrapur (CT),North Twenty
Four Parganas,West Bengal- Place of Supply : -
743248 Fulfiller Code : SH3271
Phone No : NIL/8276820306/
E-mail Id :
Intermediary Code : BA0000239311
Proposer GSTIN : - :
Name Mr.SUBODH DAS
Proposal date : 22/11/2016
Date of Inception of first policy : 22-NOV-2016 Phone No : 9339239920/9339239920
Renewal Year : Second Year
E-mail Id :
Receipt No : 1143010745
Collection Date : 22/11/2018
Premium :Rs 2,880 /-
CGST @9% :Rs 259 /- SGST / UTGST @9% :Rs 259 /-
Stamp Duty :Rs 1 /- Total Premium :Rs 3398 /-
Total Premium In Words : Rupees Three Thousand Three Hundred Ninety Eight Only
PERIOD OF INSURANCE : 22/11/2018 00:00 TO : Midnight Of 21/11/2019

Details of Insured Persons : No. of Persons Insured: 1

Sl. Name Sex Date of Birth Age in Relationship Sum Insured Cumu.Bon Add On ID Card No Pre Existing Inception
no. Yrs with Proposer (Rs.) us (Rs.) Covers Disease Date

1 SUDEB M 06/09/1983 35 SELF 200000 20000 Nil 6122635-1 NIL 22/11/2016

MONDAL
Expenses relating to the hospitalisation will be in proportion to the room rent stated in the policy.
Condition No. 4 regarding delay in payment of claim shall read as follows and not as stated in policy wordings:
"The Company shall pay interest as per Insurance Regulatory and Development Authority of India (Protection of Policyholders' Interests)
Regulations, 2017, in case of delay in payment of an admitted claim under the Policy"

Entered by : SH11593 For Star Health and Allied Insurance Company Ltd.

Approved by : SH11593

Authorised Signatory
IRDAI Regn. No 129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in Please see overleaf 2 of 4

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
 Attached to and forming part of Policy No : P/191111/01/2019/010073

IMPORTANT
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.
Sector Classification :

Urban
Toll Free No : 1800 425 2255 / 1800 102 4477 Email: support@starhealth.in Fax No: 1800 425 5522.

In the event of the policy being withdrawn in future, intimation about the withdrawal will be sent 3 months prior to the date when renewal falls
due.The insured will have the option of migrating to any other similar health insurance policy offered by the Company at the relevant time.
Continuity of benefits for waiting period and bonus, if any and if applicable, will be given provided the insured had been renewing the policy without
any break (or renewing within the grace period offered)

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 GOLAPI MONDAL Mother 25 100

Additional terms under Renewability

In the event of this policy being withdrawn / modified with revised terms and / or premium with the prior approval of the Competent Authority, the
insured will be intimated three months in advance and accommodated in any other equivalent health insurance policy offered by the Company, if
requested for by the Insured Person, at the relevant point of time.
It is hereby made clear that all terms, conditions, clauses, warranties, exclusions etc., as already issued, forming part of the policy of
insurance originally issued at the time of inception of this relationship, shall continue to be operative and unaltered, forming part of this
renewal insurance cover also.

Reference may be made to those terms, conditions etc., for identifying the scope/extent of coverage.

Other excluded expenses as detailed in our website "www.starhealth.in"

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - North Kolkata on 22nd
Day of November 2018.

Entered by : SH11593 For Star Health and Allied Insurance Company Ltd.

Approved by : SH11593

Authorised Signatory

Please see overleaf 3 of 4

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

Policy No : P/191111/01/2019/010073 Type Of Policy : Mediclassic Individual Revised

Issue Office : 191111 - Branch Office - North Kolkata

Address : First floor, 229/2, Acharya Prafulla Chandra

Road,
Kolkata - 700 004

Toll Free No : 033 - 25302533 / 25302534

Email : northkolkata@starhealth.in

This is to certify that SUDEB MONDAL has paid Rs 3398 (Total Premium In Words : Indian Rupees Three Thousand
Three Hundred Ninety-Eight Only ) towards Premium for Hospitalization Insurance vide Policy No: P/191111/01/2019/010073
for the Period 22-NOV-18 To 21-NOV-19 issued on 22-NOV-18 .
Payment received by Cheque/Credit/Debit Card vide collection No:1143010745

Note :- This Certificate must be surrendred 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.

For and on behalf of

Star Health and Allied Insurance Company Ltd.

Authorised Signatory

Entered by : SH11593 For Star Health and Allied Insurance Company Ltd.

Approved by : SH11593

Authorised Signatory

Please see overleaf 4 of 4

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