IMPORTANT

07/05/2019
To,

Mr.TRIPATI RADHA KRISHNA,

D.NO.6-18-10/A,kakarla street
Peddapuram
Peddapuram
Peddapuram,East Godavari,Andhra Pradesh -533437
Mobile : 9848141950.

Dear Customer,

Re: Health Insurance Policy - P/131311/01/2020/000501

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=PVS LAKSHMIPRASAD,

PVS SERIALNUMBER=9e461d073974cff564ee9ba39dcb9f6c1b1fe484d
e3bff77fe99ff653e852cf9, ST=TAMIL NADU, OID.2.5.4.17=600034,
OID.2.5.4.20=f3ee9487609ce79ea7ec5376e598b6d168aea6cf8c12
a55def3e9f67c0dfaa15, OU=Technical, O=STAR HEALTH AND
LAKSHMIPRASAD ALLIED INSURANCE COMPANY LIMITED, C=IN. Date :Tue May
07 17:18:18 IST 2019

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
 Family Health Optima Insurance Plan
Unique Identification No. IRDAI/HLT/SHAI/P-H/V.III/129/2017-18
Policy Schedule

In consideration of payment of Rs.20077 /- towards renewal premium of Policy number: P/131311/01/2019/000450, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No P/131311/01/2020/000501

GSTIN : 37AAJCS4517L1ZX
Customer Code : AA0001911669
Customer Name : Mr.TRIPATI RADHA KRISHNA SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 3553491 Issuing Office Code : 131311
Proposer Name : Mr.TRIPATI RADHA KRISHNA Issuing Office Name : Branch Office - Kakinada
Address : D.NO.6-18-10/A,kakarla street Address : Door No. 6-1-29, First Floor,Near
Peddapuram Nookalamma Temple,
Peddapuram Beside.IOC Petrol Bunk,jawhar Street,
Peddapuram,East Godavari,Andhra Suryarao Peta, Kakinada-533004.
Pradesh-533437
Tel/Mobile : 9848141950/9848141950/ Tel/Mobile : 0884-2343681
E-mail id : rktripathy99@gmail.com E-mail id : kakinada@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 19/05/2014 Fulfiller Code : SH13944
Date of Inception of first policy : 19-MAY-14
Intermediary Code : BA0000327724
Renewal Year : Fifth Year
Collection Number & : 1055000574 & 07/05/2019 Name : Ms.SRI LAKSHMI MANTRI
Date
Premium : Rs 17015 /- Tel/Mobile : 9866121148/9866121148
CGST @9% : Rs 1,531 /- SGST / UTGST @9% : Rs 1,531 /-
Total Premium : Rs 20077 /- Stamp Duty : Re 1 /- E-mail id : PRABHAKARMVVS@GMAIL.C
OM
Total Premium In Words : Rupees Twenty Thousand Seventy Seven Only

Period of insurance : From : 19/05/2019 00:00:00 To : Midnight of 18/05/2020

Basic Floater Sum Insured : 500000 Scheme Description : 2A+2C
In words : Rupees: Five Lakhs Only
Bonus: Rs. 325000 Limit of Coverage : Rs. 825000 Recharge Benefit : Rs. 150000
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 T RADHA KRISHNA M 25/12/1969 49 SELF 3553491-1 No PED declared 19/05/2014
2 T RADHARANI F 02/03/1979 40 SPOUSE 3553491-2 No PED declared 19/05/2014
3 T SIMHESH M 10/04/2002 17 DEPENDANT 3553491-3 No PED declared 19/05/2014
CHILD
4 T VEDA PRIYA F 27/11/2004 14 DEPENDANT 3553491-4 No PED declared 19/05/2014
CHILD

Entered By : PREMIA This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Schedule). Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10
IRDAI Regn. No 129
Corporate Identity Number U66010TN2005PLC056649
Email ID : support@starhealth.in 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 :U66010TN2005PLC056649 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/131311/01/2020/000501
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

Sector Classification

Urban

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).

Condition No. 3 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"
Condition No: 13 of the policy wordings should read as follows
"Automatic Termination: The insurance under this policy shall terminate immediately on the earlier of the following events:
* Upon the death of the Insured Person This means that, the cover for the surviving members of the family will continue, subject to other terms of
the policy.
* Upon exhaustion of the Basic Sum Insured, Basic Sum Insured plus Bonus, Basic Sum Insured plus Bonus plus Restore and / or Recharge
Sum Insured."
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.
Toll Free No : 1800 425 2255 / 1800 102 4477 Email: support@starhealth.in, Fax No: 1800 425 5522 .

"Consolidated Stamp duty paid vide Proceeding No : GSO5/2925/2018 Dated 22/05/2018"

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 - Kakinada on 07th
Day of May 2019.

Entered By : PREMIA This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Schedule). Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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

Policy No P/131311/01/2020/000501 Type Of Policy : Family Health Optima Insurance - 2017

Issue Office 131311 - Branch Office - Kakinada
Address Door No. 6-1-29, First Floor,Near
Nookalamma Temple,
Beside.IOC Petrol Bunk,jawhar Street,
Suryarao Peta, Kakinada-533004.
Toll Free No 0884-2343681
Email kakinada@starhealth.in

This is to certify that Mr.TRIPATI RADHA KRISHNA has paid Rs 20077 (Total Premium In Words : Indian Rupees Twenty
Thousand Seventy-Seven Only ) towards Premium for Hospitalization Insurance vide Policy No: P/131311/01/2020/000501
for the Period 19-MAY-19 To 18-MAY-20 issued on 07-MAY-19 .
Payment received by Cheque/Credit/Debit Card vide collection No:1055000574 1055000574 07-MAY-19

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 Star Health and Allied Insurance Company Ltd.

Authorised Signatory

Entered By : PREMIA This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Schedule). Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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 TAX Invoice

Invoice No. 37B055Y20P000127 Customer ID AA0001911669

Invoice Date 07/05/19 Policy No P/131311/01/2020/000501
Recipient Supplier

GSTIN : - GSTIN : 37AAJCS4517L1ZX

Proposer Name : Mr.TRIPATI RADHA KRISHNA NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Kakinada
Address : D.NO.6-18-10/A,kakarla street Tel/Mobile : Door No. 6-1-29, First Floor,Near
Peddapuram Nookalamma Temple,
Peddapuram Beside.IOC Petrol Bunk,jawhar Street,
Suryarao Peta, Kakinada-533004.
City : Peddapuram,East Godavari,Andhra City : KAKINADA
Pradesh-533437
State : State : Andhra Pradesh
Pincode : 533437 Pincode : 533 004
Client Category : IND Place of Supply : 37 - Andhra Pradesh

HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% Total Invoice Value
SAC Service(s)
A B C=A-B D = C * IGST E=C F = C *UTGST H = C + D + E+
Code
*CGST or SGST F
Insurance Services 17015 0 17015 1531 1531 Rs. 20077
997133
Total Invoice Value (in Figures) : Rs. 20077
Total Invoice Value (in Words) : Rupees: Twenty thousand seventy-
seven 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

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

Entered By : PREMIA This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Schedule). Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

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