STAR COMPREHENSIVE HEALTH INSURANCE POLICY

Schedule
Unique Identification No.SHAHLIP22040V102223

In consideration of payment of Rs.26,550/- towards renewal premium of Policy number: P/141142/10/2023, the policy stands
renewed for a further period of 1 year as per the details given below.

Renewal Endorsement No : P/141142/01/2023

Customer Code : AA00154316 GSTIN : 29AAJCS4517L1ZU
Customer Name : SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code Issue Office Code : 141142
: 18407279
Proposer's Name Issue Office Name : Branch Office - Indiranagar III

Address : Address : No 57 3rd & 4th Floor,

adesh - 517501 Double Road Indiranagar,
Bangalore 560 038

Phone No Phone No : 080 - 41616154

E-mail Id E-mail Id : Indiranagar3.bo@starhealth.in

Proposer GSTIN : - Place of Supply : -

Proposal Date : 05/10/2022 Fulfiller Code : SO141142

Date of Inception of first policy : 12-OCT-2022
Renewal Year : First Year
Collection Number : 1719003214
Collection Date : 12/10/2022 : LC0000000549
Premium :Rs 22,500 /- Intermediary Code
: M/S.AB INSURANCE BROKERS
IGST @ 18% : 4,050 /- Name
PVT LTD
Stamp Duty :Re 1 /- Total Premium :Rs 26,550/-
Phone No : 186030704215/6289016242

E-mail Id : cengage@abibpl.com
Total Premium In Words : Rupees Twenty Six Thousand Five Hundred Fifty Only
: 12/10/2032 00:00
Period Of Insurance From Hrs To : Midnight Of 11/10/2024
Policy Type : Individual

Installment Facility Optn :No Premium Payment Frequency :Annual Installment Amount Rs. : 0
Details of Insured Persons :
Sl. Name Sex
Age in OP Limit ID Card No Sum Inception Date
Date of Relationship with
No. Rs. Insured
Birth Yrs Proposer
(Rs.)

1400 18407269-1
1 M 25/03/1970 53 FATHER 10,00,000 12/10/2023

Details of Pre Existing Diseases relating to the above person : Cataract & its related diseases & complications

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
TAX Invoice

Invoice No. : 29G719Y22P000212 Customer ID : AA0015431666

Policy No
Invoice Date : 12/10/23 : P/141142/10/2022/003310
Recipient Supplier

GSTIN
GSTIN : : 29AAJCS4517L1ZU
Proposer's : NAME
: Star Health and Allied Insurance Co
Name Ltd - Branch Office - Indiranagar III
Address : Address : No 57 3rd & 4th Floor,
Double Road Indiranagar,
Bangalore 560 038

-
City : Andhra Pradesh - 517501 City : INDIRANAGAR III
State :
State : Andhra Pradesh Karnataka
Pincode Pincode :
: 517501 560038
Place of Supply
Client Category : IND : 29 - Karnataka
HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% CESS@1% Total InvoiceValue
SAC Service(s)
Code A B C=A-B D = C * IGST E=C F=C G=C*Cess H=C+D+E+F+G
*CGST *UTGST or
SGST

997133 Insurance 22,500 0 22,500 4,050 Rs. 26,550

Services
Total Invoice Value (in Figures) : Rs. 26,550

Total Invoice Value (in Words) : Rupees: Twenty-six thousand five

hundred fifty only
Amount of Tax Subject to reverse Charge : No

Important Note:

The invoice is issued as per Section 31 of the IGST 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 U66010TN2005PLC056649 Email ID: stargst@starhealth.in
Entered by : PREMIA For Star Health and Allied Insurance Company Ltd.

Approved by : PORTAL

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