Star Health And Allied Insurance Company Limited

Date : 28-Jan-2024
To, IMPORTANT

V. RAJAGOPAL ,
S/O. VENKATACHALAM,
NEW NO. 297, MANGALAM ROAD,
TIRUPUR - 641 604.
Tiruppur,Tamil Nadu-641604
Mobile : 97XXXXXX23

Dear Customer,

Re: Health Insurance Policy - 11240658742315

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 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.

Page 1 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :[email protected] Website :www.starhealth.in
IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Star Health Assure Insurance Policy

Unique Identification No. SHAHLIP23131V022223
POLICY SCHEDULE
Policy No. : 11240658742315 Previous Policy No : P/121122/01/2023/011045
Customer Code : AA0000040798 GSTIN : 33AAJCS4517L1Z5
Customer Name : V. RAJAGOPAL SAC Code : 997133 / Accident and Health
Insurance Services
Proposer Code : AA0000040798 Issuing Office Code : 121122
Proposer Name : V. RAJAGOPAL Issuing Office Name : Branch Office - Erode II
Proposer Address : S/O. VENKATACHALAM, Issuing Office Address : T S. NO : 78, JAYAM TOWERS
NEW NO. 297, MANGALAM ROAD, II FLOOR, ANNAMALAI
TIRUPUR - 641 604. GOUNDER LAYOUT
Tiruppur Tamil Nadu 641604 OPP NALLI HOSPITAL ROAD
Erode Town Tamil Nadu
638011
Phone No : 97XXXXXX23 Phone No : 0424-2221345
E-mail Id : E-mail Id : [email protected]
Proposer GSTIN : NO Place of Supply : Tamil Nadu
Proposal date : 30-Jan-2009 Fulfiller Code : SH13292
Date of Inception : 30-Jan-2009
of first policy
Policy Category : Fifteenth Year Intermediary : BA0000100725
Collection No : 191386011677
Code
Collection Date : 28-Jan-2024

Premium : Rs. 52,076/-

Name : Mr.K SURESH

CGST @ 9% : Rs. 4,687/-

Phone No :9942990150
:
SGST @ 9% Rs. 4,687/-
E-mail Id : [email protected]
o.in
Total Premium : Rs. 61,450/-
Stamp Duty : Re. 1/-

Total Premium In Words : Rupees Sixty One thousand four hundred fifty only
PERIOD OF INSURANCE : From : 30-Jan-2024 00:00 To : Midnight Of 29-Jan-2025 Policy Term :1 Year
Installment Facility Option:No Premium Payment Frequency :Annual Installment Amount Rs. : 0/-
Policy Type : FLOATER Scheme Description : 2A
Basic Floater Sum Insured : Rs. 10,00,000/- Bonus : Rs. 0/-
Sum Insured In Words : Rupees Ten lakhs only
Optional Cover (Deductible) : No Deductible : Rs. 0/-
Details of Insured Persons :
Sl. Age in Relationship Inception
Name of the Insured Gender Date of Birth ID Card No
no. Yrs with Proposer date
MR. V. RAJAGOPAL AA0000040798-
1 Male 02-Jun-1951 72 Self 30-Jan-2009
1
Pre Existing Disease : DIABETIC MELLITUS
MRS. R.R. SUBBULAXMI AA0000040798-
2 Female 20-May-1959 64 Spouse 30-Jan-2011
2
Pre Existing Disease : HYPER TENSION

Entered by : SH22739 For Star Health and Allied Insurance Company Ltd.
Approved by : SH22739
IRDAI Regn.No.129

Corporate Identity Number L66010TN2005PLC056649

Authorised Signatory Page 2 of 5
Email ID: [email protected]

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :[email protected] Website :www.starhealth.in
IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Attached to and forming part of Policy No: 11240658742315

Nominee Details:
Nominee Details for the Proposer Appointee Details
S.No Name Relationship Age % of the Appointee Name Appointee Relationship
with proposer claim Age with nominee

1 R.R.SUBBULAXMI Spouse 64 100

Sector Classification:
Urban

''CONSOLIDATED STAMP DUTY PAID VIDE G.O.(RT) NO.244 DATED.2ND JUNE 2023''

Please check whether the details given by you about the insured person(s) 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).
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.
Toll Free No : 1800 425 2255 Email: [email protected], Fax No: 1800 425 5522.

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch
Office - Erode II on 28th Day of January 2024.

Entered by : SH22739 For Star Health and Allied Insurance Company Ltd.
Approved by : SH22739

Authorised Signatory Page 3 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :[email protected] Website :www.starhealth.in
IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Tax Invoice
Invoice No. : 332401I012360446 Customer ID : AA0000040798
Invoice Date : 28-Jan-2024 Policy No. : 11240658742315
Recipient Supplier
GSTIN : GSTIN : 33AAJCS4517L1Z5
Name : V. RAJAGOPAL Name : Star Health and Allied Insurance Co Ltd -
Branch Office - Erode II
Address : S/O. VENKATACHALAM, Address : T S. NO : 78, JAYAM TOWERS
NEW NO. 297, MANGALAM ROAD, II FLOOR, ANNAMALAI GOUNDER LAYOUT
TIRUPUR - 641 604. OPP NALLI HOSPITAL ROAD
City : Tiruppur Pin Code : 641604 City : Erode Town Pin Code : 638011

State : Tamil Nadu Client : IND State : Tamil Nadu Place of : Tamil Nadu
Category supply

Taxable IGST @ UT/SGST @ CESS @ Total Invoice

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

Insurance
997133 52,076.00 0 52,076.00 0 4,687.00 4,687.00 0 61,450.00
Services

Total Invoice Value (in Figures) : Rs. 61,450/-

Total Invoice Value (in Words) : Rupees Sixty One thousand four hundred fifty 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
"I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate
turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule."
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: [email protected]

Entered by : SH22739 For Star Health and Allied Insurance Company Ltd.
Approved by : SH22739

Authorised Signatory Page 4 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :[email protected] Website :www.starhealth.in
IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Annexure 3A
Forming part of Policy Number : 11240658742315

Covering Flu Vaccination Approved by ICMR under Health Check Up benefit

Notwithstanding anything stated to the contrary in the within mentioned policy it is hereby agreed and declared
that this Policy would hereinafter provide the following cover without charging additional premium till 31.03.2024:

Cover for Flu Vaccine Approved by ICMR under Health check up benefit as per relevant clause with the same limits
and conditions provided therein.

Entered by : SH22739 For Star Health and Allied Insurance Company Ltd.
Approved by : SH22739

Authorised Signatory Page 5 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :[email protected] Website :www.starhealth.in
IRDAI Regn.no: 129