Star Health And Allied Insurance Company Limited

Date : 21-Feb-2025
To, IMPORTANT

LAKSHMINARAYANAGUPTHA KOTA,
2-6-10/A, RAMTHUMIYA VARI VEEDHI
BESIDE VISHNALAYAM, KAVALI
KAVALI
Kavali Mandal,Andhra Pradesh-524201
Mobile : 9885810670

Dear Customer,

Re: Health Insurance Policy - 6521112401002984

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 [Link] 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.

This is an electronically generated document(Policy

Schedule). CONSOLIDATED STAMP DUTY FOR POLICY
STAMPS PAID VIDE PROCS NO: GSO5/2990/2024
DT:20/52024

Page 1 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
CN=NAGARAJAN RANGANATHAN,
NAGARAJAN
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
SERIALNUMBER=571a5eb638953f23a816eb6b4ba547263f54f12c3eb01eeff
e482ca5cef2a530, ST=KARNATAKA, OID.[Link]=560097,
IRDAI [Link]: 129
OID.[Link]=6790b30666b75b5b38bb63bf7adee63ad3d22e5d7442f0f2901f
RANGANATHAN 2e91fd09c393, OID.[Link]=3d419b0bb1a244e29097659c201722ac,
O=PERSONAL, C=IN. Date :Fri Feb 21 [Link] IST 2025
 Star Health And Allied Insurance Company Limited

Star Health Assure Insurance Policy

Unique Identification No. SHAHLIP23131V022223

In Consideration of payment of Rs. 28,765/- towards renewal premium of policy

number:11240730985300, the policy stands renewed for a further period of 1 Year as per the details
given below

Renewal Endorsement No:6521112401002984

Customer Code : PI0005117442 GSTIN : 37AAJCS4517L1ZX
Customer Name : LAKSHMINARAYANAGUPTHA KOTA SAC Code : 997133 / Accident and Health
Cust CKYC No : 30032816102318 Insurance Services

Proposer Code : PI0005117442 Issuing Office Code : 613009

Proposer Name : LAKSHMINARAYANAGUPTHA Issuing Office Name : Branch Office - Kavali
KOTA
Proposer Address : 2-6-10/A, RAMTHUMIYA VARI Issuing Office Address : 2-8-69, 2-8-70
VEEDHI 3Rd Floor
BESIDE VISHNALAYAM, KAVALI Opp Town Court Center,Trunk
KAVALI Road
Kavali Mandal Andhra Pradesh Kavali Mandal Andhra Pradesh
524201 524201
Phone No : 9885810670 Phone No :
E-mail Id : GUPTHA1293@[Link] E-mail Id :
Proposer GSTIN : NO Place of Supply : Andhra Pradesh
Proposal date : 27-Feb-2024 Fulfiller Code : SH52934
Date of Inception : 27-Feb-2024
of first policy
Renewal Year : First Year Intermediary : BA0000632206
Collection No : 613009/RV/2025/0199044289
Code
Collection Date : 21-Feb-2025
Premium : Rs. 24,377/- Name : KOTA VENKATA
SATYA SAI SREE
TEJA
CGST @ 9% : Rs. 2,194/-
Phone No :9966704083/996670408
3
:
SGST @ 9% Rs. 2,194/-
E-mail Id : sritejakota999@gmail.
com
Total Premium : Rs. 28,765/-
Stamp Duty : Re. 1/-

Total Premium In Words : Rupees Twenty Eight thousand seven hundred

sixty five only
PERIOD OF INSURANCE : From : 27-Feb-2025 00:00 To : Midnight Of 26-Feb-2026 Policy Term :1 Year
Installment Facility Option:No Premium Payment Frequency :Annual Installment Amount Rs. : 0/-
Policy Type : FLOATER Scheme Description : 2A
Basic Floater Sum Insured : Rs. 10,00,000/- Bonus : Rs. 1,25,000/-
Sum Insured In Words : Rupees Ten lakhs only
Optional Cover (Deductible) : No Deductible : Rs. 0/-
Entered by : IG This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : IG Schedule). CONSOLIDATED STAMP DUTY FOR POLICY
STAMPS PAID VIDE PROCS NO: GSO5/2990/2024
IRDAI [Link].129 DT:20/52024
Corporate Identity Number L66010TN2005PLC056649
Authorised Signatory Page 2 of 5
Email ID: info@[Link]

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129
 Star Health And Allied Insurance Company Limited

Attached to and forming part of Policy No: 6521112401002984

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
KOTA VENKATESWARA RAO
1 Male 08-Apr-1970 54 Father ME0442939946 27-Feb-2024

Pre Existing Disease : No PED Declared

KOTA LAKSHMI
2 Female 09-Jan-1975 50 Mother ME0442939947 27-Feb-2024

Pre Existing Disease : No PED Declared

Nominee Details:
Nominee Details for the Proposer Appointee Details
[Link] Name Relationship Age % of the Appointee Name Appointee Relationship
with proposer claim Age with nominee

1 KOTA LAKSHMI Mother 50 100

Sector Classification:
Urban Urban

''CONSOLIDATED STAMP DUTY FOR POLICY STAMPS PAID VIDE PROCS NO: GSO5/2990/2024 DT:20/52024''

Please check whether the details given by you about the insured person(s) 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 Email: support@[Link], 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 [Link]

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch
Office - Kavali on 21st Day of February 2025.
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 : IG This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : IG Schedule). CONSOLIDATED STAMP DUTY FOR POLICY
STAMPS PAID VIDE PROCS NO: GSO5/2990/2024
DT:20/52024

Authorised Signatory Page 3 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 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 : 6521112401002984 Type of Policy : Assure Insurance-2021

Issue Office : 613009-Branch Office - Kavali

Address : 2-8-69, 2-8-70

3Rd Floor
Opp Town Court Center,Trunk Road
Kavali Mandal Andhra Pradesh 524201

Tel / Fax :

Email :

This is to certify that LAKSHMINARAYANAGUPTHA KOTA has paid Rs 28,765/- (Total Premium : Indian
Rupees Twenty Eight thousand seven hundred sixty five only ) towards Premium for Hospitalization Insurance
vide Policy No: 6521112401002984 for the Period 27-Feb-2025 To 26-Feb-2026 issued on 21-Feb-2025.

Payment received by Payment Gateway vide Receipt No: 613009/RV/2025/0199044289/1 Receipt

Date: 21-Feb-2025

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 : 21-Feb-2025 For and on behalf of

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

IRDAI [Link].129

Corporate Identity Number L66010TN2005PLC056649 Authorised Signatory

Email ID: info@[Link]

Entered by : IG This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : IG Schedule). CONSOLIDATED STAMP DUTY FOR POLICY
STAMPS PAID VIDE PROCS NO: GSO5/2990/2024
DT:20/52024

Authorised Signatory Page 4 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129
 Star Health And Allied Insurance Company Limited

Tax Invoice
Invoice No. : 982502I001716800 Customer ID : PI0005117442
Invoice Date : 21-Feb-2025 Policy No. : 6521112401002984
Recipient Supplier
GSTIN : GSTIN : 37AAJCS4517L1ZX
Name : LAKSHMINARAYANAGUPTHA KOTA Name : Star Health and Allied Insurance Co Ltd -
Branch Office - Kavali
Address : 2-6-10/A, RAMTHUMIYA VARI VEEDHI Address : 2-8-69, 2-8-70
BESIDE VISHNALAYAM, KAVALI 3Rd Floor
KAVALI Opp Town Court Center,Trunk Road
City : Kavali Mandal Pin Code : 524201 City : Kavali Mandal Pin Code : 524201

State : Andhra Pradesh Client : IND State : Andhra Pradesh Place of : Andhra 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 24,377.00 0 24,377.00 0 2,194.00 2,194.00 0 28,765.00
Services

Total Invoice Value (in Figures) : Rs. 28,765/-

Total Invoice Value (in Words) : Rupees Twenty Eight thousand seven hundred sixty five 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 [Link].129 Corporate Identity Number L66010TN2005PLC056649 Email ID: stargst@[Link]

Entered by : IG This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : IG Schedule). CONSOLIDATED STAMP DUTY FOR POLICY
STAMPS PAID VIDE PROCS NO: GSO5/2990/2024
DT:20/52024

Authorised Signatory Page 5 of 5

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129