Star Health And Allied Insurance Company Limited

Date : 31-Jul-2024
To, IMPORTANT

GAUTAM SHRIVASTAV,
A/85 DURGA NAGAR UKHARRA RAJPUR CHUNGi
AGRA
.
Agra Tehsil,Uttar Pradesh-282001
Mobile : 99XXXXXX13

Dear Customer,

Re: Health Insurance Policy - 11230070169802

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.

Page 1 of 6

Registered Office : No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034. Phone : 044 - 2828 8800 Corporate
Office : No. 148, Acropolis, Dr. Radha Krishnan Salai, Mylapore, Chennai - 600 004. Phone : 044 - 4788 6666 Toll Free No:1800-425-2255 /
1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@starhealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Young Star Insurance Policy

(Floater)
Unique Identification No. SHAHLIP22036V042122
POLICY SCHEDULE
In Consideration of payment of Rs. 14,316/- towards renewal premium of policy
number:11230070169801, the policy stands renewed for a further period of 1 Year as per the details
given below

Renewal Endorsement No:11230070169802

Customer Code : PI0000498355 GSTIN : 09AAJCS4517L1ZW
Customer Name : GAUTAM SHRIVASTAV SAC Code : 997133 / Accident and Health
Cust CKYC No : - Insurance Services

Proposer Code : PI0000498355 Issuing Office Code : 231115

Proposer Name : GAUTAM SHRIVASTAV Issuing Office Name : Branch Office - Agra
Proposer Address : A/85 DURGA NAGAR UKHARRA Issuing Office Address : E- 12/8, 4th floor, Shree
RAJPUR CHUNGi Vrindaven Tower,
AGRA Sanjay Palace,
. .
Agra Tehsil Uttar Pradesh 282001 Agra Town Uttar Pradesh
282002
Phone No : 99XXXXXX13 Phone No : 0562-4061570/71
E-mail Id : nsXXXXXXXX@gmail.com E-mail Id : agra@starhealth.in
Proposer GSTIN : NO Place of Supply : Uttar Pradesh
Proposal date : 28-Jul-2022 Fulfiller Code : SH28436
Date of Inception : 28-Jul-2022
of first policy
Renewal Year : Second Year Intermediary : BA0000221376
Collection No : 231115/RV/2025/0151637091
Code
Collection Date : 31-Jul-2024

Premium : Rs. 12,132/-

Name : Mr.HITENDRA
KUDASIYA
CGST @ 9% : Rs. 1,092/-
Phone No :0562-
4061570/71/9456621391
:
SGST @ 9% Rs. 1,092/-
E-mail Id : HITENDRA2222@REDI
FFMAIL.COM
Total Premium : Rs. 14,316/-
Stamp Duty : Re. 1/-

Total Premium In Words : Rupees Fourteen thousand three hundred sixteen

only
PERIOD OF INSURANCE : From : 31-Jul-2024 00:00 To : Midnight Of 30-Jul-2025 Policy Term :1 Year
Installment Facility Option:Yes Premium Payment Frequency :Quarterly Installment Amount Rs. : 3,579/-
Scheme Description :2A+2C Basic Floater Sum Insured :Rs. 5,00,000/-
Bonus :Rs. 2,00,000/-
Total Sum Insured In Words :Rupees Five lakhs only Plan Type :SILVER

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

Corporate Identity Number L66010TN2005PLC056649

Authorised Signatory Page 2 of 6
Email ID: info@starhealth.in

Registered Office : No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034. Phone : 044 - 2828 8800 Corporate
Office : No. 148, Acropolis, Dr. Radha Krishnan Salai, Mylapore, Chennai - 600 004. Phone : 044 - 4788 6666 Toll Free No:1800-425-2255 /
1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@starhealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Attached to and forming part of Policy No: 11230070169802

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
GAUTAM SHRIVASTAV
1 Male 25-Aug-1994 29 Self PI0000498355 28-Jul-2022

Pre Existing Disease : No PED Declared

AKSHITA SHRIVASTAV
2 Female 19-Jan-2022 2 Daughter ME0257490278 28-Jul-2022

Pre Existing Disease : No PED Declared

ISHAN SHRIVASTAV
3 Male 07-Oct-2020 3 Son ME0257490279 28-Jul-2022

Pre Existing Disease : No PED Declared

SONIYA SEVITA
4 Female 05-Jul-1991 33 Spouse ME0416203445 31-Jul-2023

Pre Existing Disease : No PED Declared

Installment Premium Table
Total Installment Premium
S.No. Installment Due Dt. Premium Amount (Rs) GST Amount (Rs)
Amount (Rs)
1 31-Jul-2024 3,033 546 3,579
2 31-Oct-2024 3,033 546 3,579
3 31-Jan-2025 3,033 546 3,579
4 30-Apr-2025 3,033 546 3,579

The following Conditions shall apply.

i. Grace Period of 7 days would be given to pay the iv. No interest will be charged lf the instalment premium
instalment premium due for the policy is not paid on due date.

ii. During such grace period, coverage will not be v. ln case of instalment premium due not received
available from the due date of instalment premium till within the grace period, the policy will get cancelled.
the date of receipt of premium by Company.
vi. ln the event of a claim, all subsequent premium
iii. The insured person will get the accrued continuity instalments shall immediately become due and payable.
benefit in respect of the "Waiting Periods", "Specific
Waiting Periods" in the event of payment of premium vii. The company has the right to recover and deduct all
within the stipulated grace Period. the pending installments from the claim amount due
under the policy.

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 SONIYA SEVITA Spouse 33 100

Sector Classification:
Urban

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

Authorised Signatory Page 3 of 6

Registered Office : No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034. Phone : 044 - 2828 8800 Corporate
Office : No. 148, Acropolis, Dr. Radha Krishnan Salai, Mylapore, Chennai - 600 004. Phone : 044 - 4788 6666 Toll Free No:1800-425-2255 /
1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@starhealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

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.
Toll Free No: 1800 425 2255/1800 102 4477 Email: support@starhealth.in, 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 here in to set his hand at Branch Office - Agra on 31st Day of
July 2024.
As per Section 34 of CGST Act of 2017, Policy Issued in one Financial Year and Cancelled in another Financial Year
on or after 01st of December, then Only Premium Amount will be Refunded to the Customer and GST Amount will
Not be Refunded. Customer has to Claim the Refund of GST Amount from the GST Portal.

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

Authorised Signatory Page 4 of 6

Registered Office : No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034. Phone : 044 - 2828 8800 Corporate
Office : No. 148, Acropolis, Dr. Radha Krishnan Salai, Mylapore, Chennai - 600 004. Phone : 044 - 4788 6666 Toll Free No:1800-425-2255 /
1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@starhealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Hospitalisation Benefit Policy

Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986

Policy No : 11230070169802 Type of Policy : Young Star Insurance Policy

Issue Office : 231115-Branch Office - Agra

Address : E- 12/8, 4th floor, Shree Vrindaven Tower,

Sanjay Palace,
.
Agra Town Uttar Pradesh 282002

Tel / Fax : 0562-4061570/71

Email : agra@starhealth.in

This is to certify that GAUTAM SHRIVASTAV has paid Rs 3,579/- (Total Premium : Indian Rupees Three
thousand five hundred seventy nine only ) towards Premium for Hospitalization Insurance vide Policy No:
11230070169802 for the Period 31-Jul-2024 To 30-Jul-2025 issued on 31-Jul-2024.

Payment received by Payment Gateway vide Receipt No: 231115/RV/2025/0151637091/1 Receipt

Date: 31-Jul-2024

Note :- This Certificate must be surrendered 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.

Date : 31-Jul-2024 For and on behalf of

Place : Branch Office - Agra Star Health and Allied Insurance Company Ltd.

IRDAI Regn.No.129

Corporate Identity Number L66010TN2005PLC056649 Authorised Signatory

Email ID: info@starhealth.in

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

Authorised Signatory Page 5 of 6

Registered Office : No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034. Phone : 044 - 2828 8800 Corporate
Office : No. 148, Acropolis, Dr. Radha Krishnan Salai, Mylapore, Chennai - 600 004. Phone : 044 - 4788 6666 Toll Free No:1800-425-2255 /
1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@starhealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Tax Invoice
Invoice No. : 092407I004123028 Customer ID : PI0000498355
Invoice Date : 31-Jul-2024 Policy No. : 11230070169802
Recipient Supplier
GSTIN : GSTIN : 09AAJCS4517L1ZW
Name : GAUTAM SHRIVASTAV Name : Star Health and Allied Insurance Co Ltd -
Branch Office - Agra
Address : A/85 DURGA NAGAR UKHARRA RAJPUR Address : E- 12/8, 4th floor, Shree Vrindaven Tower,
CHUNGi
AGRA Sanjay Palace,
. .
City : Agra Tehsil Pin Code : 282001 City : Agra Town Pin Code : 282002

State : Uttar Pradesh Client : IND State : Uttar Pradesh Place of : Uttar Pradesh
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 12,132.00 0 12,132.00 0 1,092.00 1,092.00 0 14,316.00
Services

Total Invoice Value (in Figures) : Rs. 14,316/-

Total Invoice Value (in Words) : Rupees Fourteen thousand three hundred sixteen 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: stargst@starhealth.in

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

Authorised Signatory Page 6 of 6

Registered Office : No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034. Phone : 044 - 2828 8800 Corporate
Office : No. 148, Acropolis, Dr. Radha Krishnan Salai, Mylapore, Chennai - 600 004. Phone : 044 - 4788 6666 Toll Free No:1800-425-2255 /
1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@starhealth.in Website :www.starhealth.in IRDAI Regn.no: 129