IMPORTANT

To,

SHANNO TIWARI,
H-590, WORLD BANK, BARRA, KANPUR NAGAR
UTTAR PRADESH

Kanpur,Kanpur Nagar,Uttar Pradesh

Mobile : 8072104042.

Dear Customer,

Re: Health Insurance Policy - P/700002/01/2023/022646

We are extremely thankful for availing health insurance from us and we enclose the policy along with the terms and
conditions.

The said policy has been prepared based on the details furnished by you in the proposal form (copy enclosed) and
the medical reports, wherever applicable. We shall thank you if you can verify the policy to ensure that all the details
are incorporated correctly as per the proposal. In case of any discrepancy noticed, please communicate the same to
us immediately. You will appreciate that it is the primary duty of the proposer to fill the proposal form and also to
make sure that the proposal contains all the details correctly so also the policy has incorporated the details correctly.

This insurance policy is subject to various exclusions including exclusion for pre-existing diseases and conditions in
this policy. If there is suppression of any material fact in the proposal, the contract shall become null and void ab
initio.

We would like to mention that we have incorporated the name of the intermediary as indicated by you in the proposal
who will be of assistance to you.

The policy is subject to the condition of "free look period". As per this condition, a free look period of 15 days from
the date of receipt of the policy is available to you to review the terms and conditions of the policy. In case you are
not satisfied with the terms and conditions, you may seek cancellation of the policy and in such an event, we shall
allow refund of premium paid after adjusting the cost of pre-acceptance medical screening, if any, stamp duty
charges, and proportionate risk premium for the period on cover, provided no claim has been made until such
cancellation.

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 select the room as per your eligibility stipulated in your policy to avoid additional payment from your pocket
towards the proportionate increase which would invariably be charged by the hospital for the higher room category
occupied.

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 Jun 13 14:17:07 IST 2022

1 of 8

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
 SENIOR CITIZENS RED CARPET HEALTH INSURANCE POLICY
Schedule
Unique Identification No.SHAHLIP22199V062122
Policy No. : P/700002/01/2023/022646 Previous Policy No. :
Customer Code : AA0026223521 GSTIN : 27AAJCS4517L1ZY
Customer Name : SHANNO TIWARI SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 29604515 Issue Office Code : 700002
Proposer's Name : SHANNO TIWARI Issue Office Name : Online Business
Address : H-590, WORLD BANK, BARRA, Address : 349 Business Point, Unit No.204 /
KANPUR NAGAR 205,2nd Floor, Near Sai Service,
UTTAR PRADESH Western Express Highway,
Andheri (E), Mumbai -400069
Kanpur,Kanpur Nagar,Uttar Pradesh -
208027
Phone No : /8072104042/ Phone No : 1800-425-2255
E-mail Id : gokuliphone@gmail.com E-mail Id : online@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal Date : 13/06/2022 Fulfiller Code : SO700002
Date of Inception of first policy : 13/06/2022
Renewal Year : NEW
Receipt No : 1272030678
Receipt Date : 13/06/2022 Intermediary Code : OL0000000001
Premium :Rs 112,279 /- Name : Direct
IGST @18% : 20,208 /-
Stamp Duty :Re 1 /- Total Premium :Rs 132,487 /- Phone No :/

E-mail Id :

Total Premium In Words : Rupees One Lakh Thirty Two Thousand Four Hundred Eighty Seven Only
Period Of Insurance From : 13/06/2022 14:17:12 Hrs To : Midnight Of 12/06/2025
Floater Sum Insured Rs. 1000000 OP Limit Rs. 2400 Policy Type : Floater
Installment Facility Optn :Yes Premium Payment Frequency :Quarterly Installment Amount Rs. : 11038
Details of Insured Persons :
Sl. Sex Date of Age in Relationship with ID Card No Inception Date
Name Co-Pay
No. Birth Proposer
Yrs
1 SHANNO TIWARI F 05/09/1955 66 SELF 29604515-1 30 13/06/2022
Details of Pre Existing Diseases relating to the above person : Hypertension and its complications

2 ARUN KUMAR TIWARI M 01/11/1960 61 SPOUSE 29604515-2 30 13/06/2022

Details of Pre Existing Diseases relating to the above person : NONE

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

Approved by : PORTAL

IRDAI Regn. No 129

Corporate Identity Number L66010TN2005PLC056649
Email ID : info@starhealth.in Authorised Signatory

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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
Attached to and forming part of Policy No. P/700002/01/2023/022646
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 dishonour of premium cheque(s), the Company shall not be liable under the policy and the policy shall be void abinitio
(from inception).
Expenses relating to the hospitalisation will be considered in proportion to the room rent stated in the policy.

THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC. ATTACHED.
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.

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

"CONSOLIDATED STAMP DUTY PAID VIDE PROCEEDING NO.LOA/CSD/324/2022/1696 DATED 19-APR-2022"

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)

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Online Business on 13th Day
of June 2022.
Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

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

Approved by : PORTAL

Authorised Signatory

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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
Attached to and forming part of Policy No. P/700002/01/2023/022646
INSTALLMENT PREMIUM CLAUSE

Sr.No. Installment Due Dt. Premium Amount GST Amount Total Installment Premium Amount

1 13-JUN-22 9354 1684 11038

2 12-SEP-22 9357 1684 11041

3 12-DEC-22 9357 1684 11041

4 12-MAR-23 9357 1684 11041

5 12-JUN-23 9357 1684 11041

6 12-SEP-23 9357 1684 11041

7 12-DEC-23 9357 1684 11041

8 12-MAR-24 9357 1684 11041

9 12-JUN-24 9357 1684 11041

10 12-SEP-24 9357 1684 11041

11 12-DEC-24 9357 1684 11041

12 12-MAR-25 9357 1684 11041

Total : 112279 20208 132487

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

Approved by : PORTAL

Authorised Signatory

4 of 8

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

Policy No : P/700002/01/2023/022646 Type Of Policy :

Issue Office : 700002 - Online Business

Address : 349 Business Point, Unit No.204 / 205,2nd

Floor, Near Sai Service,
Western Express Highway,
Andheri (E), Mumbai -400069
Toll Free No : 1800-425-2255
Email : online@starhealth.in

This is to certify that SHANNO TIWARI has paid Rs 11038 (Total Premium In Words : Indian Rupees Eleven Thousand
Thirty-Eight Only ) towards Premium for Hospitalization Insurance vide Policy No: P/700002/01/2023/022646 for the Period
13-JUN-22 To 12-JUN-25 issued on 13-JUN-22 .
Payment received by Cheque/Credit/Debit Card vide collection No:1272030678

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.

Star Health and Allied Insurance Company Ltd.

Authorised Signatory

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

Approved by : PORTAL

Authorised Signatory

5 of 8

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
 Star Health and Allied Insurance
Emergency Help Line No. 1800 425 2255 / 1800 102 4477 Company Limited
e-mail : support@starhealth.in Website : www.starhealth.in Customer Identity Card
Please quote the Customer Id No. for assistance
Customer ID No. : 29604515-1
This Card is valid until otherwise Cancelled.
Name : SHANNO TIWARI
This ID Card is invalid, if the insurance cover is not in force.
Immediate intimation to 'Star' through above Tel Nos. is a must Date Of Birth : 05-SEP-55 Age : 66 Years
in case of Hospitalisation. Gender : Female Office Code : 700002
Valid From : 13-JUN-22 TA/SSM/SM Code: SO700002
At the time of hospitalization, kindly submit any Government
approved photo ID Card. Agent/Broker/TE Code: OL0000000001

Corporate Identity Number: L66010TN2005PLC056649 IRDAI Regn. No:129

Star Health and Allied Insurance

Company Limited
Customer Identity Card

Customer ID No. : 29604515-2

Name : ARUN KUMAR TIWARI
Date Of Birth : 01-NOV-60 Age : 61 Years
Gender : Male Office Code : 700002
Valid From : 13-JUN-22 TA/SSM/SM Code: SO700002
Agent/Broker/TE Code: OL0000000001

IRDAI Regn. No:129

*This is a temporary ID card issued along with the policy. Original ID cards will be dispatched shortly.

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

Approved by : PORTAL

Authorised Signatory

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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
 TAX Invoice

Invoice No. : 27C272Y23P003745 Customer ID : AA0026223521

Invoice Date : 13/06/22 Policy No : P/700002/01/2023/022646
Recipient Supplier

GSTIN : - GSTIN : 27AAJCS4517L1ZY

Proposer's : SHANNO TIWARI NAME : Star Health and Allied Insurance Co
Name Ltd - Online Business
Address : H-590, WORLD BANK, BARRA, Address : 349 Business Point, Unit No.204 /
KANPUR NAGAR 205,2nd Floor, Near Sai Service,
UTTAR PRADESH Western Express Highway,
Andheri (E), Mumbai -400069
City : Kanpur,Kanpur Nagar,Uttar City : ONLINE BUSINESS
Pradesh
State : Uttar Pradesh State : Maharashtra
Pincode : 208027 Pincode : 400069
Client Category : IND Place of Supply : 27 - Maharashtra

HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% CESS@1% Total InvoiceValue
SAC Service(s) H=C+D+E+F+G
A B C=A-B D = C * IGST E=C F=C G=C*Cess
Code
*CGST *UTGST or
SGST
997133 Insurance 118188 5909 112279 20208 Rs. 132487
Services
Total Invoice Value (in Figures) : Rs. 132487
Total Invoice Value (in Words) : Rupees: One lakh thirty-two
thousand four hundred eighty-
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 L66010TN2005PLC056649 Email ID:stargst@starhealth.in

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

Approved by : PORTAL

Authorised Signatory

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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
 Name Of the Product Senior Citizens Red Carpet Health Insurance Policy

Product UIN No. SHAHLIP22199V062122

Summary of Important Benefits-Floater

Refer to
S.No Particulars of Coverage / Benefits Benefit Limits (in Rs.) Policy clause
No.

Sum Insured (in Rs.) 10,00,000 15,00,000 20,00,000 25,00,000

Room Rent (Per Day) Up to -

1 *Hospitalization expenses will be considered in proportion to the Room Rent 7,000 2(A)
6,000 8,500 10,000
stated in the policy or actuals whichever is less

2 ICU Charges (Per Day) - Up to 20,000 Actuals Actuals Actuals 2(B)

Surgeon, Anesthetist, Medical Practitioner,

3 Maximum of 25% of the Sum Insured per hospitalization 2(C)
Consultants, Specialist Fees - Up to

Anaesthesia, Blood, Oxygen, Operation Theatre charges, Surgical Appliances,

Maximum of 50% of the Sum Insured per hospitalization
4 Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, 2(D)
Chemotherapy, Radiotherapy, cost of Pacemaker and similar expenses - Up to

Limit Per hospitalization 1,000 1,500 1,500 1,500

5 Emergency Ambulance 2(E)
Limit Per policy period 3,000 3,000 3,000
2,000

6 Pre-Hospitalization Medical Expenses Up to 30 days prior to the date of hospitalization 2(F)

Post-Hospitalization Medical Expenses (Limit Per Occurrence) -

7 Equivalent to 7% of the hospitalization expenses comprising of Nursing 7,000
7,000 10,000 10,000 2(G)
Charges, Surgeon / Consultant fees, Diagnostic charges, Medicines and drugs
expenses subject to a maximum of
Point no1
Day Care Procedures / Treatments All Day Care Procedures are Covered under
8
Important note

Out Patient Medical Consultations incurred in a Limit Per person - Up to 1,400 1,800 2,200 2,600
9 Network Hospital (Limit per policy period)
Limit Per policy period - Up to 2(H)
(Note: Limit of Rs.200/- is applicable per Consultation) 2,400 3,000 3,800 4,400

Cost of Health Check-up - Up to Limit Per person - Up to 2,000 2,000 2,500 2,500
(for every claim free year provided the health check-up is done at
10 2(I)
network hospitals and the policy is in force) Limit Per policy period - Up to 3,500 3,500 4,500 4,500

11 Cataract (Limit Per person, per policy period) Limit Per person - Up to 25,000 30,000 35,000 40,000

Limit Per policy period - Up to 45,000 50,000 60,000 70,000

. Cerebrovascular Accident,
Limit Per person - Up to 3,50,000 4,00,000 4,50,000 Refer table
12
. Cardiovascular Diseases, 5,00,000
under
. Cancer (Including Chemotherapy / Radiotherapy), Coverage
. Medical Renal Diseases (Including Dialysis),
. Treatment of Breakage of Long Bones Limit Per policy period - Up to 6,00,000 7,00,000 7,50,000 8,50,000
(Limit Per person, per policy period for each disease / condition) - Up
to

Limit Per person - Up to 2,75,000 3,00,000 3,25,000 3,50,000

All other major surgeries
(Limit Per person, per policy period for each disease / condition) - Up to
Limit Per policy period - Up to 4,50,000 5,00,000 5,50,000 6,00,000

Co-payment
13 30% for all Claims 2(K)
(Applicable on each and every admissible claim)

14 Coverage for Modern Treatments Covered up to the limits 2(J)

15 Instalment Facility (if Opted) Available

4(13)

Note: The above information is only indicative. For complete details of the Terms & Conditions kindly read the policy wordings attached.

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

Approved by : PORTAL

Authorised Signatory

8 of 8

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