IMPORTANT

To, 16-NOV-21

Mr.MOHAMMAD KAIF AIFAZ AHMED

PLOT NO = 33/A AVANT NAGAR RATHOD LAYOUT
KATOL ROAD NAGPUR
NAGPUR
Nagpur,Nagpur,Maharashtra -440013
Mobile : 7498551207.

Dear Customer,

Re: Health Insurance Policy - P/151120/01/2022/011181

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
"Let Star Health help you to become healthier and happier. Star Wellness Benefits includes Mind Body healing and other
Condition management programmes (Weight management, Diabetes etc....) Visit www.starhealth.in / customer portal login and
start your journey with us to Better Health".

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.
CN=R Margabandhu,

R Margabandhu
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b154
However, the ultimate decision will be that of yours only. 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 :Tue Nov 16 19:38:22 IST 2021

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
 YOUNG STAR INSURANCE POLICY
SCHEDULE (Individual)
UNIQUE ID:SHAHLIP22036V042122

Policy No. : P/151120/01/2022/011181 Previous Policy No. :

Customer Code : AA0021735951 GSTIN : 27AAJCS4517L1ZY
Customer Name : Mr.MOHAMMAD KAIF AIFAZ SAC Code : 997133/Accident and Health Insurance Services
AHMED
Proposer's Code : 24991228 Issuing Office Code : 151120
Proposer's Name : Mr.MOHAMMAD KAIF AIFAZ Issuing Office Name : Branch Office - Nagpur II
AHMED
Address : PLOT NO = 33/A AVANT NAGAR Address : 16, Gandhi Grain Market
RATHOD LAYOUT Near Telephone Exchange
KATOL ROAD NAGPUR Square,
NAGPUR Opp.Axis Bank,C.A Road,Nagpur
Nagpur,Nagpur,Maharashtra- - 440008
440013
Phone No : -/7498551207/ Phone No : 0712-6688701 / 0712-6688702
E-mail Id : E-mail Id : [email protected]
Proposer GSTIN : - Place of Supply : -
Proposal date : 16/11/2021 Fulfiller Code : SH5176

Date of Inception of first policy : 16-NOV-2021

Renewal Year : NEW
Intermediary Code : BA0000135889
Collection Number : 1295011961 Name : Ms.ARCHANA A GUPTA
Receipt Date : 16/11/2021

Premium :Rs 4,405 /- Phone No : /8055577296

CGST @9% : 396 /- SGST / UTGST @9% : 396 /- : [email protected]
E-mail Id
Stamp Duty :Rs 1 /- Total Premium :Rs 5,197 /- m
Total Premium In Words : Rupees Five Thousand One Hundred Ninety Seven Only Installment Facility Optn :No

Premium Payment Frequency : Annual Installment Amount Rs. : 0

Period of Insurance : FROM 16/11/2021 16:48 TO : Midnight Of 15/11/2022 Term : 1 Year

Details of Insured Persons :

Age in Relationship ID Card No Plan Sum Insured Bonus

Pre Existing Disease Inception
Sl. Name of the Insured Sex Date of with Date
Yrs
no. Birth Proposer
1 MOHAMMAD KAIF AIFAZ M 02/10/2001 20 SELF 24991228-1 GOLD 300000 0 No PED declared 16/11/2021
AHMED

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.

Entered by : SH37808 For Star Health and Allied Insurance Company Ltd.
Approved by : SH37808

IRDAI Regn. No 129

Authorised Signatory
Corporate Identity Number U66010TN2005PLC056649
Email ID : [email protected]
2 of 6

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
Attached to and forming part of Policy No : P/151120/01/2022/011181

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).

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: [email protected], Fax No: 1800 425 5522
"CONSOLIDATED STAMP DUTY PAID VIDE PROCEEDING No.CSD/116/2021/3138/21 DATED 23-AUG-2021"

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 SHABANA ANJUM Mother 43 100

AHMED
In witness whereof the undersigned being authorised by and on behalf of the company has set his hand at Branch Office - Nagpur II on 16th
Day of November 2021.

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

Entered by : SH37808 For Star Health and Allied Insurance Company Ltd.
Approved by : SH37808

Authorised Signatory

3 of 6

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
 Star Health and Allied Insurance
Company Limited
Emergency Help Line No. 1800 425 2255 / 1800 102 4477
e-mail : [email protected] Website : www.starhealth.in Customer Identity Card

Please quote the Customer Id No. for assistance Customer ID No. : 24991228-1
This Card is valid until otherwise Cancelled. Name : MOHAMMAD KAIF AIFAZ AHMED
This ID Card is invalid, if the insurance cover is not in force Date Of Birth : 02-OCT-01 Age : 20 Years
Immediate intimation to 'Star' through above Tel Nos. is a must
Gender : Male Office Code : 151120
in case of Hospitalisation.
At the time of hospitalization, kindly submit any Government Valid From : 16-NOV-21 TA/SSM/SM Code : SH5176
approved photo ID Card. Agent/Broker/TE Code : BA0000135889
Corporate Identity Number: U66010TN2005PLC056649 IRDAI Regn. No:129

Entered by : SH37808 For Star Health and Allied Insurance Company Ltd.
Approved by : SH37808

Authorised Signatory

4 of 6

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
 TAX Invoice

Invoice No. : 27H295Y22P000656 Customer ID : AA0021735951

Invoice Date : 16/11/21 Policy No : P/151120/01/2022/011181
Recipient Supplier

GSTIN : - GSTIN : 27AAJCS4517L1ZY

Proposer's : Mr.MOHAMMAD KAIF AIFAZ NAME : Star Health and Allied Insurance Co Ltd
Name AHMED - Branch Office - Nagpur II
Address : PLOT NO = 33/A AVANT NAGAR Address : 16, Gandhi Grain Market
RATHOD LAYOUT Near Telephone Exchange Square,
KATOL ROAD NAGPUR Opp.Axis Bank,C.A Road,Nagpur - 440008
NAGPUR
City : Nagpur,Nagpur,Maharashtra- City : NAGPUR II
440013
State : Maharashtra State : Maharashtra
Pincode : 440013 Pincode : 440008
Client Category : IND Place of Supply : 27 - Maharashtra

HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% CESS@1% Total Invoice Value
SAC Service(s) G=C*Cess H =C+D+E +F+G
Code A B C=A-B D = C * IGST E=C F=C
*CGST *UTGST or
SGST

997133 Insurance 4405 0 4405 396 396 Rs. 5197

Services
Total Invoice Value (in Figures) : Rs. 5197
Total Invoice Value (in Words) : Rupees: Five thousand one
hundred ninety-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 : SH37808 For Star Health and Allied Insurance Company Ltd.
Approved by : SH37808

Authorised Signatory

5 of 6

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
 Name Of the Product YOUNG STAR INSURANCE POLICY
Product UIN No. SHAHLIP22036V042122
Summary of Important Benefits
Benefit Limits (in Rs.) Refer to Policy
Particulars of Coverage /
S.No clause No.
Benefits Individual Individual and Floater
Sum Insured (in Rs.) 300000/- 500000/- 1000000/- 1500000/- 2000000/- 2500000/- 5000000/- 7500000/- 10000000/-
1 Plan Type Gold Plan
Room Rent (Per Day) - Up to
2 *Hospitalization expenses will be
considered in proportion to the eligible Single Private A/c Room II(A)
Room Rent
Surgeon, Anesthetist, Medical
3 Practitioner, Consultants, Specialist
Fees, Anesthesia, blood, oxygen,
operation theatre charges, Surgical Actual II(B & C)
Appliances, Medicines and Drugs

Road Ambulance charges(per policy

4 Subject to admissible hospitalisation claims II(D)
period)

5 Pre-Hospitalization Expenses Up to 60 days prior to admission II(E)

6 Post-Hospitalization Expenses Up to 90 days from the date of discharge II(F)
7 Day Care Procedure All day care procedure covered. II(G)
8 Medical Opinion E -Medical Opinion" from the Company's expert panel. II(H)
Sum Insured/policy type Rs3,00,000/- Rs5,00,000/- Rs10,00,000/- Rs15,00,000/-and above
9. Health Check Individual 1,500/- 2,000/- 3,000/- 3,500/- II(I)
up
Floater N/A 3,000/- 4,000/- 5,000/-
Automatic Restoration of Basic Sum
10
Insured Once during policy period by 100% II(J)

11 Cumulative bonus
The insured person will be eligible for Cumulative bonus calculated at 20% of basic sum II(K)
insured for each claim free year subject to a maximum of 100% of the basic sum insured.
Additional Basic Sum Insured for Road 25% of the Sum Insured subject to a maximum of Rs10,00,000/-
12 Traffic Accident (RTA)
II(L)

Delivery expenses Expenses for a Delivery including Delivery by Caesarean section up-to Rs.30,000/- per III(A)
13
delivery is payable up to the Basic Sum Insured

Hospital Cash Benefit upto 7 days per

14 occurrence & upto 14 days per policy
The Company will pay a Cash Benefit of Rs.1000/-for each completed day of III(B)
hospitalization subject to a maximum of 7 days per hospitalization and 14 days per policy
period. (1 day deductible)
period,

15 Star Wellness Program Discount in the Renewal premium for healthy life style through wellness activities. II(M)
16 Special Features 10% Discount at the time of renewal after 40years of age. V(22 A)

17 Coverage for Modern Treatment Covered up to the limits II(N)

18 Instalment Facility (If Opted) Available V(13)

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

Entered by : SH37808 For Star Health and Allied Insurance Company Ltd.
Approved by : SH37808

Authorised Signatory

6 of 6

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