STAR HEALTH AND ALLIED INSURANCE COMPANY LTD
FAMILY HEALTH OPTIMA
Unique Reference No. SHAI/PR0001
Following are the details entered to obtain your policy
Proposer Details:
Name : ANIL GHOLAP Social Sector classification:
Date Of Birth : April 03, 1966 Social Sector : No
Occupation : CLERICAL/SUPERVISORY AND
RELATED WORKERS Residence Address :
Annual Income : 250000 Address Line 1 : 39- MAMTA COLONY NEAR GANESH
PAN Number : TEMPLE KHAJRANA
GST ID Number : Address Line 2 : INDORE DIST INDORE M. P.
Aadhaar Number : 406745054875 Pin Code : 452001
Do you have an : No State : Madhya Pradesh
eIA number? City/Village : Indore (M Corp+OG)
Area : Indore (M Corp+OG)
Communication Address:
Address Line 1 : 39- MAMTA COLONY NEAR GANESH
TEMPLE KHAJRANA
Address Line 2 : INDORE DIST INDORE M. P. Do you have any other health insurance covering the persons
Pin Code : 452001 proposed in the past or current?
State : Madhya Pradesh :
City/Village : Indore (M Corp+OG)
Area : Indore (M Corp+OG)
Mobile : 8461806825 Appointee Details:
Email : sagardeepika2175@gmail.com Appointee Name :
Appointee :
Nominee Details: Relation with the
Nominee Name : SAGAR GHOLAP proposer
Nominee : Son Appointee Age :
Relation with the
proposer
Nominee Age : 22
Bank Details:
Account Number : 33138594367
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Type of Account : Savings Account
Bank Name : State bank of india
Bank Branch : Goyal nagar
IFSC Code : SBIN0030412
Plan Details:
Start Date : March 11, 2018
End Date : March 10, 2019
Family Size : 2A+2C
Sum Insured : Rs. 5,00,000
Insured Details:
Insured 1
Name : ANIL GHOLAP Gender : Male
You are buying : Self Height (cms) : 165
the policy for Weight (kgs) : 62
Date of Birth : April 03, 1966
Occupation : CLERICAL/SUPERVISORY AND
RELATED WORKERS
Health History:
Do you have any health problems (if any) in the below field
NONE
Insured 2
Name : DIPEEKA GHOLAP Gender : Female
You are buying : Spouse Height (cms) : 163
the policy for Weight (kgs) : 60
Date of Birth : September 21, 1975
Occupation : HOUSEWIVES
Health History:
Do you have any health problems (if any) in the below field
NONE
Insured 3
Name : SAGAR GHOLAP Gender : Male
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You are buying : Dependant Child Height (cms) : 170
the policy for Weight (kgs) : 58
Date of Birth : August 23, 1995
Occupation : STUDENTS-SCHOOL AND COLLEGE
Health History:
Do you have any health problems (if any) in the below field
NONE
Insured 4
Name : VISHAL GHOLAP Gender : Male
You are buying : Dependant Child Height (cms) : 172
the policy for Weight (kgs) : 60
Date of Birth : November 29, 1997
Occupation : STUDENTS-SCHOOL AND COLLEGE
Health History:
Do you have any health problems (if any) in the below field
NONE
Premium Calculation:
Cover Description Amount
TOTAL PREMIUM Rs. 22,560
ADD :TAX Rs. 4,060
TOTAL AMOUNT Rs. 26,620
Medical Declaration:
Have you or any member of your family proposed to be insured, suffered or are suffering from any disease/ailment/adverse
medical condition of any kind especially Heart/Stroke/Cancer/Renal disorder/Alzheimer's disease/Parkinsons's disease
No
Declaration:
I hereby declare, on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars
given by me are true and complete in all respects to the best of my knowledge and that I am authorised to propose on behalf
of these persons. I understand that the information provided by me will form the basis of the insurance policy, is subject
to the Board approved underwriting policy of the insurance company and that the policy will come into force only after full
payment of the premium chargeable. I understand that acceptance of the proposal is subject to evaluation of the proposal
by Company's medical team I further declare that I will notify in writing any change occurring in the occupation or general
health of the person proposed for insurance after the proposal has been submitted but before communication of the risk
acceptance by the company. I declare that I consent to the company seeking medical information from any doctor or hospital
who/which at any time has attended on the person to be insured or from any past or present employer concerning anything
which affects the physical or mental health of the person to be insured and seeking information from any insurer to whom
an application for insurance on the person to be insured has been made for the purpose of underwriting the proposal and/or
claim settlement. I authorize the company to share information pertaining to my proposal including the medical records of the
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person to be insured for the sole purpose of underwriting the proposal and/or claims settlement and with any Governmental
and/or Regulatory authority.
Prohibition of rebates:
(Section 41 of the Insurance Act): No person shall allow or offer to allow either directly or indirectly as an inducement to any
person to take out or renew or continue an insurance in respect of any kind of risk relation to lives or property in India, any
rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person
taking out or renewing or continuing a policy accept rebate, except such rebate as may be allowed in accordance with the
published prospectuses or tables of the insurer.
Any person making default in complying with the provision of this section shall be liable for a penalty which may extend to ten
lakh rupees.
I also confirm that the source of funds for premium paid under this policy is legal.
I hereby agree and confirm that:
- The premium is paid for purchase of insurance policy through net banking account or credit/debit card issued in my name,
i.e. proposer/policyholder.
- And all premium has been paid from genuine sources and no premium has been paid out of proceeds of crime related to any
of the scheduled offences listed in Prevention of Money Laundering Act, 2002. I understand that the Company has the right to
call for documents to establish sources of funds. The company has right to cancel the insurance contract in case I am found
guilty by any competent court of law directly or indirectly governing prevention of money laundering in India.
Authenticated through OTP at 2018-03-10 16:41:52.0
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