IMPORTANT

To, 10-NOV-22

Mr.NELSON RODRIGUES
ANITA NAGAR CHS, BUILDING NO.8, FLAT NO. 105,
AKURLI ROAD, LOKHANDWALA TOWNSHIP,
KANDIVALI EAST, MUMBAI - 400101
Mumbai,Mumbai (Suburban),Maharashtra -400101
Mobile : 9768343573.

Dear Customer,

Re: Health Insurance Policy - P/171127/01/2023/015351

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
"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.

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 :Thu Nov 10 09:04:14 IST 2022

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 COMPREHENSIVE INSURANCE POLICY
SCHEDULE (Floater)
UNIQUE ID:SHAHLIP22028V072122

In consideration of payment of Rs.14302/- towards renewal premium of Policy number: P/171127/01/2022/013687, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No : P/171127/01/2023/015351

Customer Code : AA0010073529 GSTIN : 27AAJCS4517L1ZY
Customer Name : Mr.NELSON RODRIGUES SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 12765670 Issuing Office Code : 171127
Proposer's Name : Mr.NELSON RODRIGUES Issuing Office Name : Branch Office - Borivali East
Address : ANITA NAGAR CHS, BUILDING Address : SHOP NO 129,130,131,1ST
NO.8, FLAT NO. 105, FLOOR,
AKURLI ROAD, LOKHANDWALA HARI OM PLAZA, M.G.ROAD,
TOWNSHIP, BORIVALI - EAST,MUMBAI -
KANDIVALI EAST, MUMBAI - 400066
400101
Mumbai,Mumbai (Suburban),Maharashtra
-400101
Phone No : 8779290921/9768343573/- Phone No : 022-28947910/12/13
E-mail Id : rodrigues.nelson7@gmail.com E-mail Id : borivalieast.mumbai@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 18/11/2019 Fulfiller Code : SH7506

Date of Inception of first policy : 18-NOV-2019 Intermediary Code : BA0000058348

Renewal Year : Third Year
Collection Number : 1412016635
Receipt Date : 10/11/2022
Name : NAMDEO R KALPANDE
Premium :Rs 12,120 /- Phone No : 9869078775/9869078775
CGST @9% : 1,091 /- SGST / UTGST @9% : 1,091 /-
Stamp Duty :Rs 1 /- Total Premium :Rs 14,302 /- E-mail Id : namdeolic@gmail.com
Total Premium In Words : Rupees Fourteen Thousand Three Hundred Two Only Installment Facility Optn :No

Premium Payment Frequency :Annual Installment Amount : Rs. 0

Period of Insurance : FROM 18/11/2022 00:00 TO : Midnight Of 17/11/2023
Scheme Description (Family Size) : 2 ADULTS Basic Floater Sum Insured : Rs. 500000 /-
Bonus : Rs. 500000 /-
Sum Insured Under Section 1 (Health) Rs. 500000 /- Policy Term : 1 Year
Capital Sum Insured Under Section 10 (For Accidental Death & Permanent Total Disablement) : Rs. 500000 /-
For Mr / Ms. NELSON RODRIGUES Only.

For Star Health and Allied Insurance Company Ltd.

Entered by : PREMIA
Aproved by : PORTAL

IRDAI Regn. No 129

Authorised Signatory
Corporate Identity Number L66010TN2005PLC056649
Email ID : info@starhealth.in
2 of 4

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/171127/01/2023/015351
Details of Insured Persons :
Sl. Name of the Insured Sex Date of Birth Age in Relationship with ID Card No Co-Pay Buy Back Pre- Inception Date
no. Yrs Proposer PED Opted Existing
Disease/s
1 NELSON RODRIGUES M 07/04/1987 35 SELF 12765670-1 0 No No PED 18/11/2019
declared
2 SWATI NELSON F 11/12/1980 41 SPOUSE 12765670-2 0 No No PED 18/11/2019
RODRIGUES declared
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).

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
" CONSOLIDATED CERTIFICATE LOA/CSD/481/2022/4306 DATED 06-OCT-2022"

Nominee Details
Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 SWATI NELSON Spouse 41 100

RODRIGUES

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 authorised by and on behalf of the company has set his hand at Branch Office - Borivali East on
10th Day of November 2022.

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

For Star Health and Allied Insurance Company Ltd.

Entered by : PREMIA
Aproved by : PORTAL

Authorised Signatory

3 of 4

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. : 27H412Y23P000636 Customer ID : AA0010073529

Invoice Date : 10/11/22 Policy No : P/171127/01/2023/015351
Recipient Supplier

GSTIN : - GSTIN : 27AAJCS4517L1ZY

Proposer's : Mr.NELSON RODRIGUES NAME : Star Health and Allied Insurance Co Ltd
Name - Branch Office - Borivali East
Address : ANITA NAGAR CHS, BUILDING Address : SHOP NO 129,130,131,1ST FLOOR,
NO.8, FLAT NO. 105, HARI OM PLAZA, M.G.ROAD,
AKURLI ROAD, LOKHANDWALA BORIVALI - EAST,MUMBAI - 400066
TOWNSHIP,
KANDIVALI EAST, MUMBAI -
400101
City : City : BORIVALI EAST
State : Maharashtra State : Maharashtra
Pincode : 400101 Pincode : 400092
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 12120 0 12120 1091 1091 Rs. 14302

Services
Total Invoice Value (in Figures) : Rs. 14302
Total Invoice Value (in Words) : Rupees: Fourteen thousand three
hundred two 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

For Star Health and Allied Insurance Company Ltd.

Entered by : PREMIA
Aproved by : PORTAL

Authorised Signatory

4 of 4

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