Star Health And Allied Insurance Company Limited

Date : 26-Jun-2024
To, IMPORTANT

GAUTAM MANNA ,
TRIBENI BENIMADHAB TOLA,
P.O - TRIBENI, DIST - HOOGHLY,
PIN -
Chinsurah Magra Tehsil,West Bengal-712503
Mobile : 62XXXXXX68

Dear Customer,

Re: Health Insurance Policy - 11230054706613

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 4

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

In Consideration of payment of Rs. 44,929/- towards renewal premium of policy

number:11230054706612, the policy stands renewed for a further period of 1 Year as per the details
given below
Renewal Endorsement No:11230054706613
Customer Code : AA0000200829 GSTIN : 19AAJCS4517L1ZV
Customer Name : GAUTAM MANNA SAC Code : 997133 / Accident and Health
Cust CKYC No : - Insurance Services

Proposer Code : AA0000200829 Issuing Office Code : 191120

Proposer Name : GAUTAM MANNA Issuing Office Name : Branch Office - Serampore
Proposer Address : TRIBENI BENIMADHAB TOLA, Issuing Office Address : 153/F/3, N.S. Avenue
P.O - TRIBENI, DIST - HOOGHLY, Serampore, Hooghly
PIN - .
Chinsurah Magra Tehsil West Serampore West Bengal
Bengal 712503 712201
Phone No : 62XXXXXX68 Phone No : 033-26522060/033-
26522061/033-26522062
E-mail Id : E-mail Id : serampore.kolkata@starhealt
h.in
Proposer GSTIN : NO Place of Supply : West Bengal
Proposal date : 14-Jun-2011 Fulfiller Code : SH10623
Date of Inception : 14-Jun-2011
of first policy
Renewal Year : Thirteenth Year Intermediary : BA0000110199
Collection No : 191120/RV/2025/0140434413
Code
Collection Date : 26-Jun-2024

Premium : Rs. 38,075/-

Name : Mr.PROSENJIT
MANDAL
CGST @ 9% : Rs. 3,427/-
Phone No :9830225241/943249623
1
:
SGST @ 9% Rs. 3,427/-
E-mail Id : prosenjitmandal11@ya
hoo.com
Total Premium : Rs. 44,929/-
Stamp Duty : Re. 1/-

Total Premium In Words : Rupees Forty Four thousand nine hundred twenty
nine only
PERIOD OF INSURANCE : From : 08-Jul-2024 00:00 To : Midnight Of 07-Jul-2025 Policy Term :1 Year
Installment Facility Option:No Premium Payment Frequency :Annual Installment Amount Rs. : 0/-
Scheme Description (Family Size) :2A+2C Basic Floater Sum Insured :Rs. 5,00,000/-
Bonus : Rs. 1,50,000/- Limit of Coverage : Rs. 6,50,000/- Recharge Benefit : Rs. 1,50,000/-

Entered by : SH02312 For Star Health and Allied Insurance Company Ltd.
Approved by : SH02312
IRDAI Regn.No.129

Corporate Identity Number L66010TN2005PLC056649

Authorised Signatory Page 2 of 4
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: 11230054706613

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 MANNA AA0000200829-
1 Male 24-Jan-1961 63 Self 14-Jun-2011
1
Pre Existing Disease : No PED Declared
ANJANA DEBNATH MANNA AA0000200829-
2 Female 18-Dec-1974 49 Spouse 14-Jun-2011
2
Pre Existing Disease : No PED Declared
OLIVIYA MANNA AA0000200829-
3 Female 09-Nov-2008 15 Daughter 14-Jun-2011
3
Pre Existing Disease : No PED Declared
ANULIMA MANNA AA0000200829-
4 Female 26-Feb-2013 11 Daughter 26-Jun-2014
5
Pre Existing Disease : No PED Declared

Sector Classification:
Urban Urban

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 by and on behalf of the company has set his hand at Branch
Office - Serampore on 26th Day of June 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 : SH02312 For Star Health and Allied Insurance Company Ltd.
Approved by : SH02312

Authorised Signatory Page 3 of 4

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. : 192406I005906869 Customer ID : AA0000200829
Invoice Date : 26-Jun-2024 Policy No. : 11230054706613
Recipient Supplier
GSTIN : GSTIN : 19AAJCS4517L1ZV
Name : GAUTAM MANNA Name : Star Health and Allied Insurance Co Ltd -
Branch Office - Serampore
Address : TRIBENI BENIMADHAB TOLA, Address : 153/F/3, N.S. Avenue
P.O - TRIBENI, DIST - HOOGHLY, Serampore, Hooghly
PIN - .
City : Chinsurah Pin Code : 712503 City : Serampore Pin Code : 712201
Magra Tehsil

State : West Bengal Client : IND State : West Bengal Place of : West Bengal
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 38,075.00 0 38,075.00 0 3,427.00 3,427.00 0 44,929.00
Services

Total Invoice Value (in Figures) : Rs. 44,929/-

Total Invoice Value (in Words) : Rupees Forty Four thousand nine hundred twenty nine 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 : SH02312 For Star Health and Allied Insurance Company Ltd.
Approved by : SH02312

Authorised Signatory Page 4 of 4

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