IMPORTANT

01/12/2019
To,

Prashant Malaviya,
C - 87, Krishna Nagar
New Pali Road, Basni, Jodhpur

Jodhpur,Jodhpur,Rajasthan -342005
Mobile : 9899986958.

Dear Customer,

Re: Health Insurance Policy - P/161130/01/2020/042225

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 :Sun Dec 01 16:49:20 IST 2019

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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 :U66010TN2005PLC056649 Email :[email protected] 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.13057 /- towards renewal premium of Policy number: P/161130/01/2019/031132, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No P/161130/01/2020/042225

GSTIN : 06AAJCS4517L1Z2
Customer Code : AA0006188027
Customer Name : Prashant Malaviya SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 8302628 Issuing Office Code : 161130
Proposer Name : Prashant Malaviya Issuing Office Name : Branch Office - Gurgaon III
Address : C - 87, Krishna Nagar Address : Ist Floor,, SCO 4, Sector 14 Market
New Pali Road, Basni, Jodhpur Near Payal Cinema, Gurgaon
Gurgaon-122001
Jodhpur,Jodhpur,Rajasthan-342005

Tel/Mobile : /9899986958/ Tel/Mobile : 0124-4797452

E-mail id : [email protected] E-mail id : [email protected]
Proposer GSTIN : - Place of Supply : -
Proposal date : 10/12/2017 Fulfiller Code : SO161130
Date of Inception of first policy : 11-DEC-17
Intermediary Code : WA0000000009
Renewal Year : Second Year
Collection Number & : 1439047110 & 01/12/2019 Name : M/S.Policy Bazaar Insurance Web
Date
Premium : Rs 11065 /-
Aggregator Pvt Ltd
IGST @18% : Rs 1,992 /- Tel/Mobile : 1800-208-8787/
Total Premium : Rs 13057 /- Stamp Duty : Re 1 /-

E-mail id :

Total Premium In Words : Rupees Thirteen Thousand Fifty Seven Only

Period of insurance : From : 11/12/2019 00:00:00 To : Midnight of 10/12/2020

Basic Floater Sum Insured : 500000 Scheme Description : 2A+1C
In words : Rupees: Five Lakhs Only
Bonus: Rs. 175000 Limit of Coverage : Rs. 675000 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 Prashant Malaviya M 26/10/1983 36 SELF 8302628-1 No PED declared 11/12/2017
2 Akansha Malaviya F 14/12/1983 35 SPOUSE 8302628-2 No PED declared 11/12/2017
3 Gaurangi Malaviya F 31/07/2017 2 DEPENDANT 8302628-3 No PED declared 11/12/2017
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 : [email protected] 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 :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129

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 Attached to and forming part of Policy No. P/161130/01/2020/042225
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 Akansha Malaviya Spouse 35 100

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: [email protected], Fax No: 1800 425 5522 .

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 - Gurgaon III on 01st
Day of December 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 :[email protected] 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/161130/01/2020/042225 Type Of Policy : Family Health Optima Insurance - 2017

Issue Office 161130 - Branch Office - Gurgaon III
Address Ist Floor,, SCO 4, Sector 14 Market
Near Payal Cinema, Gurgaon
Gurgaon-122001
Toll Free No 0124-4797452
Email [email protected]

This is to certify that Prashant Malaviya has paid Rs 13057 (Total Premium In Words : Indian Rupees Thirteen Thousand
Fifty-Seven Only ) towards Premium for Hospitalization Insurance vide Policy No: P/161130/01/2020/042225 for the Period
11-DEC-19 To 10-DEC-20 issued on 01-DEC-19 .
Payment received by Cheque/Credit/Debit Card vide collection No:1439047110

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 :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129

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 TAX Invoice

Invoice No. 6I439Y20P0000128 Customer ID AA0006188027

Invoice Date 01/12/19 Policy No P/161130/01/2020/042225
Recipient Supplier

GSTIN : - GSTIN : 06AAJCS4517L1Z2

Proposer Name : Prashant Malaviya NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Gurgaon III
Address : C - 87, Krishna Nagar Tel/Mobile : Ist Floor,, SCO 4, Sector 14 Market
New Pali Road, Basni, Jodhpur Near Payal Cinema, Gurgaon
Gurgaon-122001
City : Jodhpur,Jodhpur,Rajasthan-342005 City : GURGAON III
State : Rajasthan State : Haryana
Pincode : 342005 Pincode : 122001
Client Category : IND Place of Supply : 6 - Haryana

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 11065 0 11065 1992 Rs. 13057

Total Invoice Value (in Figures) : Rs. 13057
Total Invoice Value (in Words) : Rupees: Thirteen thousand fifty-
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 : [email protected]

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 :[email protected] Website :www.starhealth.in IRDAI Regn.no: 129

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