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BA0000135013 Intermediary Code Name Phone No E-Mail Id: 55 K. Madan Prakash K. Madan Prakash 4/51, Pesil Garden, Kovur

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MEDICLASSIC INSURANCE POLICY (INDIVIDUAL)

SCHEDULE
Unique Identification No.IRDA/NL-HLT/SHAI/P-H/V.II/400/13-14

Policy No. : P/111113/01/2018/018822 Previous Policy No. : P/111113/01/2017/010855


Customer Code : AA0001022055 GSTIN : 33AAJCS4517L1Z5
Customer Name K. SASI
: V. MADAN PRAKASH
KUMAR SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 1410494 Issuing Office Code : 111113
Proposer's Name : K. MADAN PRAKASH
A.VENKATESAN Issuing Office Name : Branch Office - T Nagar
Address : 4/51,PESIL
B1, PESILGREEN,
GARDEN, Address : New No:55 Old No:27,2nd
Irandamkattalai, Floor,Vijayaraghava Road
Thandalam Post, Kovur, Chennai T-Nagar,Chennai 600 017
KOVUR, CHENNAI- 600122.
KORUR,
Chennai,Kancheepuram,Tamil Phone No : 044-43624767
Nadu-600122 E-mail Id : chennai.tnagar@starhealth.in
Phone No : /9940211792/NIL Place of Supply : -
E-mail Id : venkatesan_ar@rediffmail.com Fulfiller Code : SH3316
Proposer GSTIN : -
Proposal date : 21-DEC-13 Intermediary Code : BA0000135013
Date of Inception of first policy : 08/12/2010
Name : Ms.R PRABA
Renewal Year : Seventh Year
Receipt No : 1006012759 Phone No : /9677113503
Receipt Date : 19/12/2017
31,115 /-
Premium :Rs 11,115 /- E-mail Id : prabaraj13@gmail.com
CGST @9% :Rs 2,800
1,000 /-
/- SGST / UTGST @9% :Rs 2,800
1,000 /-
/-
36,716/-/-
Stamp Duty :Re 1 /- Total Premium :Rs 13115
Total Premium In Words Rupees
: Rupees Thirty Six
Thirteen Thousand
Thousand OneSeven Hundred
Hundred and
Fifteen Sixteen only
Only
PERIOD OF INSURANCE : 21/12/2017 00:00:00 TO : Midnight Of 20/12/2018

Details of Insured Persons : No. of Persons Insured: 1

Sl. Name Sex Date of Birth Age in Relationship Sum Insured Cumu.Bon Add On ID Card No Pre-existing Inception
no. Yrs with Proposer (Rs.) us (Rs.) Covers Disease/s Date

1 NR. KANAGARAJ
A.GOWRI
NVARADHARAJAN
VA M
F 30/8/1952
04/03/1962 65
55 DEPENDANT 2000000
300000 60000 Nil 1410494-1 Nil, Renewal; 08/12/2010
PARENT First Year
Exclusions
waived.
Expenses relating to the hospitalisation will be in proportion to the room rent stated in the policy.
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.
Sector Classification :

Urban
Toll Free No : 1800 425 2255 / 1800 102 4477 Email: support@starhealth.in Fax No: 1800 425 5522.
"Consolidated Stamp duty paid vide G.O. Rt. No.238 dated 10.5.2017"

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

This is an electronically generated


document(Policy Schedule).
Consolidated Stamp Duty paid vide Authorised Signatory
certificate NO: Adj/CS/277/102437/10

IRDAI Regn. No 129


Corporate Identity Number U66010TN2005PLC056649 Please see overleaf 2 of 4

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