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FAMILY HEALTH OPTIMA INSURANCE POLICY - SCHEDULE

Policy No. Proposer's Code Proposer's Name Address : P/700002/01/2013/011352 Previous Policy No. Issuing Office Code Issuing Office Name Address : : : : 700002 Online Business No: 7/8, Sneh Samadan, Sahar Road, Opp. Andheri Railway Station, Andheri - East, Mumbai - 400 069 ONLINE BUSINESS : 2763763 : MAHESH RAJARAM SHUKLA : 566/A,OPPOSITE GRIHINI SAMAJ SCHOOL, RAMDAS PETH,NAGPUR NAGPUR - 440010, Maharashtra NAGPUR : 9890070945/ : pratibha_2k_2000@yahoo.com

Phone No E-mail id

Toll Free No E-mail id Fulfiller Code

Proposal date : 05/03/2013 Date of Inception of first policy : 06/03/2013 Renewal Year Receipt No Receipt Date Premium : : : NEW 1272012061 05/03/2013

: 1800-425-2255 : online@starhealth.in Sector : SO700002 : :

: None

Intermediary Code Name Phone No E-mail id


TO :

OL0000000002 TeleSales / NIL

: Rs 5,555.00 /- Service Tax : Rs 687.00 /: Rs 6,242.00 /-

: :

Stamp Duty : Re 1.00 /- Total Premium Total Premium In Words PERIOD OF INSURANCE SCHEME - DESCRIPTION LIMIT OF COVERAGE Details of Insured Persons :
Sl. No. Name of the Insured Sex

: Rupees Six Thousand Two Hundred Forty-Two Only FROM : 06/03/2013 00:00:00

Midnight Of 05/03/2014
Rs 300000 /- ( Three Lakhs Only) . /-

: 2 ADULTS + 1 CHILD : Rs.300000 /-

BASIC FLOATER SUM INSURED : Bonus

: Rs .

Date of Birth

Age-Yrs/Mths

Relationship with Proposer

Pre Existing Disease/s

ID Card No

1 2 3

MAHESH RAJARAM SHUKLA ANSHUMA MAHESH SHUKLA HARSHWARDHAN MAHESH SHUKLA

MALE FEMALE MALE

18/05/1973 15/06/1975 18/08/2010

39 Yrs 9 Mths 37 Yrs 8 Mths 2 Yrs 6 Mths

SELF SPOUSE DEPENDANT CHILD

NIL NIL NIL

2763763-1 2763763-2 2763763-3

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). 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. 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 Online Business on 05th Day of March 2013.

Revision in sum insured:In case of an upward revision in sum insured on renewal, in respect of disease, sickness, illness
the sum insured will be restricted to that policy sum insured when the signs or symptoms was diagnosed or received medical advice or treatment.

Entered By

: STAR_PORTAL

For Star Health and Allied Insurance Company Ltd. This is an electronically generated document(Policy Schedule). Consolidated Stamp Duty paid vide certificate NO: Adj/CS/129/11/4152 Dated 26.09.2011.

Authorised Signatory

Kannan S

CN=Kannan S, SERIALNUMBER=f29a5b3b9c6f48e2841a06abb56 c43b5ab5647325765c9667cc1b11bd05622a2, ST=Tamil Nadu, OID.2.5.4.17=600034, OU=Star Health And Allied Insurance Company Limited, O=Star Health And Allied Insurance Company Limited, C=IN Date: 2013.03.05 10:11:50 IST

Attached to and forming part of Policy No. It is hereby declared and agreed that

P/700002/01/2013/011352

Point No 1.0 (A) appearing in the policy shall read as follows: Room, Boarding expenses as provided by the Hospital / Nursing Home at: 2% of the Sum Insured, subject to a maximum of Rs.5,000/- per day in Class "A" Cities, 1% of the Sum Insured, subject to a maximum of Rs.3,000/- per day in Class "B" Cities and 1% of the Sum Insured, subject to a maximum of Rs.1,000/- per day in other locations. Further the definition of Class A and Class B cities mentioned in the policy stands amended as follows: Class "A" cities means Ahmedabad, Bangalore, Chennai, Hyderabad including Secunderabad, Kolkata, Mumbai including Thane, Pune , New Delhi including Noida, Gurgaon,Faridabad and Ghaziabad Class "B" cities means Agra, Baroda, Coimbatore, Cochin, Indore, Kanpur, Ludhiana, Surat, Meerut, Jalandhar, Amritsar , Nagpur and All State Capitals other than those falling under Class "A". Other Locations means Rest of India not falling under Class A and Class B above. All other terms and conditions of the policy remain unaltered.

Entered By

: STAR_PORTAL

For Star Health and Allied Insurance Company Ltd. This is an electronically generated document(Policy Schedule). Consolidated Stamp Duty paid vide certificate NO: Adj/CS/129/11/4152 Dated 26.09.2011.

Authorised Signatory

Hospitalisation Benefit Policy Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986 Policy No Issue Office Address : P/700002/01/2013/011352 : 700002 - Online Business : No: 7/8, Sneh Samadan, Sahar Road, Opp. Andheri Railway Station, Andheri - East, Mumbai - 400 069 Toll Free No Email : 1800-425-2255 : online@starhealth.in Type Of Policy : FHO-Policy

This is to certify that MAHESH RAJARAM SHUKLA has paid Rs 6242 (Total Premium In Words : Indian Rupees Six Thousand Two Hundred Forty-Two Only ) towards Premium for Hospitalization Insurance vide Policy No: P/700002/01/2013/011352 for the Period 06-MAR-13 To 05-MAR-14 issued on 05-MAR-13 . Payment received by Cheque/Credit/Debit Card vide collection No: 1272012061 - 05/03/2013 Note :- This Certificate must be surrendred 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.

For Star Health and Allied Insurance Company Ltd.

Authorised Signatory

Star Health and Allied Insurance Company Limited Customer Identity Card Customer ID No. : 2763763-1 Name Date of Birth Gender Valid From Office Code : MAHESH RAJARAM SHUKLA : 18/05/1973 : M : 06/03/2013 : 700002 Personal and Caring Emergency Help Line No. 1800 425 2255 / 044 2826 3300 E-mail: support@starhealth.in Website: www.starhealth.in Please quote the Customer ID No. for assistance Immediate intimation to Star through above Telephone number is a must in the case of Hospitalisation. This card to be produced at the time of Hospitalization along with the valid photo identity proof. This ID card is invalid, if the insurance cover is not in force. This card is valid until otherwise cancelled. Age : 39 Years

Star Health and Allied Insurance Company Limited Customer Identity Card Customer ID No. : 2763763-2 Name Date of Birth Gender Valid From Office Code : ANSHUMA MAHESH SHUKLA : 15/06/1975 : F : 06/03/2013 : 700002 Personal and Caring Emergency Help Line No. 1800 425 2255 / 044 2826 3300 E-mail: support@starhealth.in Website: www.starhealth.in Please quote the Customer ID No. for assistance Immediate intimation to Star through above Telephone number is a must in the case of Hospitalisation. This card to be produced at the time of Hospitalization along with the valid photo identity proof. This ID card is invalid, if the insurance cover is not in force. This card is valid until otherwise cancelled. Age : 37 Years

Star Health and Allied Insurance Company Limited Customer Identity Card Customer ID No. : 2763763-3 Name Date of Birth Gender Valid From Office Code : HARSHWARDHAN MAHESH SHUKLA : 18/08/2010 : M : 06/03/2013 : 700002 Personal and Caring Emergency Help Line No. 1800 425 2255 / 044 2826 3300 E-mail: support@starhealth.in Website: www.starhealth.in Please quote the Customer ID No. for assistance Immediate intimation to Star through above Telephone number is a must in the case of Hospitalisation. This card to be produced at the time of Hospitalization along with the valid photo identity proof. This ID card is invalid, if the insurance cover is not in force. This card is valid until otherwise cancelled. Age : 2 Years