IMPORTANT

02/03/2022
To,

Mr.DR. BISWAJAYA SHARMA,

PLOT NO. 226, WATER TANK LANE
VENUS INN STREET , BAPUJINAGAR
BHUBANESWAR, KHORDHA
Bhubaneswar,Khordha,ODISHA -751009
Mobile : 9937349094.

Dear Customer,

Re: Health Insurance Policy - P/619004/01/2022/000724

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.

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 :Mon Apr 04 20:10:24 IST 2022

1 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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Family Health Optima Insurance Plan
SHAHLIP22030V062122
Policy No. : P/619004/01/2022/000724 Previous Policy No. : P/619004/01/2021/000681
Customer Code : AA0017648411 GSTIN : 21AAJCS4517L1ZA
Customer Name : Mr.DR. BISWAJAYA SHARMA SAC Code : 997133/Accident and Health Insurance Services
Proposer Code : 20727760 Issuing Office Code : 619004
Proposer Name : Mr.DR. BISWAJAYA SHARMA Issuing Office Name : Branch Office - Kendrapara
Address : PLOT NO. 226, WATER TANK LANE Address : 1ST Flr, Plot No 65 At/PoKapaleswar Dist,
VENUS INN STREET , Odisha,
BAPUJINAGAR Kendrapara - 754211.
BHUBANESWAR, KHORDHA
Bhubaneswar,Khordha,ODISHA-
751009
Tel/Mobile : 0/9937349094/0 Tel/Mobile : 06727 232343
E-mail id : drbiswaayush@gmail.com E-mail id : Kendrapara.bo@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 10/03/2021 Fulfiller Code : SH56747
Date of Inception of first policy : 10-MAR-2021
Intermediary Code : BA0000542510
Renewal Year : First Year
Collection Number & : 1596000917 & 02/03/2022 Name : MAHENDRA DAS
Date
Premium : Rs 13370 /- Tel/Mobile : 8847896114/8847896114
CGST @9% : Rs 1,203 /- SGST / UTGST @9% : Rs 1,203 /-
Total Premium : Rs 15776 /- Stamp Duty : Re 1 /- E-mail id : mahendra.vicky55@gmail.com

Total Premium In Words : Rupees Fifteen Thousand Seven Hundred Seventy Six Only
Installment Facility Optn :No Premium Payment Frequency :Annual Installment Amount Rs. : 0

Period of insurance : From : 10/03/2022 00:00 To : Midnight of 09/03/2023

Basic Floater Sum Insured : 1000000
In words : Rupees: Ten Lakhs Only
Bonus: Rs. 250000 Limit of Coverage : Rs. 1250000 Recharge Benefit : Rs. 150000
Scheme Description : 2ADULT+1CHILD
Details of Insured Persons :

Sl. Name of the Insured Gender Date of Birth Age in Relationship ID Card No Pre Existing Disease Inception Date
No. Yrs with Proposer
1 Dr.BISWAJAYA M 26/05/1989 32 SELF 20727760-1 No PED declared 10/03/2021
SHARMA
2 Dr.RAJALAXMI F 05/06/1989 32 SPOUSE 20727760-2 No PED declared 10/03/2021
SHARMA
3 SAI SHREE SHARMA F 10/06/2014 7 DEPENDANT 20727760-3 No PED declared 10/03/2021
CHILD

Entered By : SH52366 For Star Health and Allied Insurance Company Ltd.
Approved By : SH52366

Authorised Signatory

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

2 of 4
 Attached to and forming part of Policy No. P/619004/01/2022/000724
Nominee Details

Nominee Details for the proposer Appointee Details

Relationship Age % of Appointee Relationship

S.No. Name Age
with proposer the Name with Nominee
claim

1 Dr. RAJALAXMI SHARMA Spouse 32 100

Sector Classification

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).

THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED.
"This policy covers 68 other excluded expenses. Accordingly, exclusion (Code Excl 37) appearing in the policy wordings stands
deleted"

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 .
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Kendrapara on 02nd
Day of March 2022.

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

Entered By : SH52366 For Star Health and Allied Insurance Company Ltd.
Approved By : SH52366

Authorised Signatory

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

3 of 4
 TAX Invoice

Invoice No. : 21L596Y22P000003 Customer ID : AA0017648411

Invoice Date : 02/03/22 Policy No : P/619004/01/2022/000724
Recipient Supplier

GSTIN : - GSTIN : 21AAJCS4517L1ZA

Proposer Name : Mr.DR. BISWAJAYA SHARMA NAME : Star Health and Allied Insurance Co Ltd
- Branch Office - Kendrapara
Address : PLOT NO. 226, WATER TANK Tel/Mobile : 1ST Flr, Plot No 65 At/PoKapaleswar
LANE Dist,
VENUS INN STREET , Odisha,
BAPUJINAGAR Kendrapara - 754211.
BHUBANESWAR, KHORDHA
City : Bhubaneswar,Khordha,ODISHA- City : KENDRAPARA
751009
State : ODISHA State : Odisha
Pincode : 751009 Pincode : 754211
Client Category : IND Place of Supply : 21 - Odisha

HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% CESS@1% Total Invoice Value
SAC Service(s)
A B C=A-B D = C * IGST E=C F = C *UTGST G=C*Cess H=C+D+E+F+G
Code
*CGST or SGST

997133 Insurance Services 13370 0 13370 1203 1203 Rs. 15776

Total Invoice Value (in Figures) : Rs. 15776
Total Invoice Value (in Words) : Rupees: Fifteen thousand seven
hundred seventy-six 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

Corporate Identity Number U66010TN2005PLC056649 Email ID : stargst@starhealth.in

Entered By : SH52366 For Star Health and Allied Insurance Company Ltd.
Approved By : SH52366

Authorised Signatory

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 :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129

4 of 4