STAR HEALTH AND ALLIED INSURANCE COMPANY LTD

Family Health Optima Insurance Plan

IRDAI/HLT/SHAI/P-H/V.III/129/2017-18

Following are the details entered to obtain your policy

Proposer Details:

Name : Venkata Ravi Shankar Kolluru Social Sector classification:

Date Of Birth : July 04, 1981 Social Sector : No
Occupation :
Annual Income : Second Nominee Details:
Nationality : Indian Citizen Nominee Name :
PAN Number : bvepk6764r Nominee :
GST ID Number : Relation with the
Aadhaar Number : 566462823771 proposer

Do you have an : No Nominee Age :

eIA number? Nominee Claim :
Percent

Communication Address:
Second Appointee Details:
Communication : c2c, plaza verdant acres ph2, gandhi
Address Line 1 nagar 3rd street Appointee Name :

Communication : nookampalyam road Appointee :

Address Line 2 Relation with the
proposer
Pin Code : 600100
Appointee Age :
State : Tamil Nadu
City/Village : Chennai
Area : Officers Colony Tirusulam
Mobile : 9963403737
Email : raviskolluru@gmail.com

Residence Address:
Residence : c2c, plaza verdant acres ph2, gandhi
Address Line 1 nagar 3rd street
Residence : nookampalyam road
Address Line 2
Pin Code : 600100
State : Tamil Nadu
City/Village : Chennai
Area : Officers Colony Tirusulam

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Nominee Details:
Nominee Name :
Nominee :
Relation with the
proposer
Nominee Age :
Nominee Claim :
percent

Appointee Details:
Appointee Name :
Appointee :
Relation with the
proposer
Appointee Age :

Do you have any other health insurance covering the persons proposed in the past or current :

Plan Details:

Start Date : October 07, 2018

End Date : October 06, 2019
Family Size : 2A+2C
Sum Insured : Rs. 10,00,000

Insured Details:

Insured 1

Name : Venkata Ravi Shankar Kolluru Gender : Male

You are buying : Self Height (cms) : 174
the policy for Weight (kgs) : 78
Date of Birth : July 04, 1981
Occupation :

Health History:
Do you have any health problems? Has the person proposed for insurance been advised for treatment of sub-fertility /
infertility?
NONE

Insured 2

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Name : kolluru prasanthi Gender : Female
You are buying : Spouse Height (cms) : 168
the policy for Weight (kgs) : 65
Date of Birth : August 13, 1988
Occupation :

Health History:
Do you have any health problems? Has the person proposed for insurance been advised for treatment of sub-fertility /
infertility?
NONE

Insured 3

Name : kolluru laasya Gender : Female

You are buying : Dependant Child Height (cms) : 0
the policy for Weight (kgs) : 0
Date of Birth : April 10, 2012
Occupation :

Health History:
Do you have any health problems?
NONE

Insured 4

Name : kolluru sravya Gender : Female

You are buying : Dependant Child Height (cms) : 0
the policy for Weight (kgs) : 0
Date of Birth : September 08, 2017
Occupation :

Health History:
Do you have any health problems?
NONE

Premium Calculation:
Cover Description Amount
TOTAL PREMIUM Rs. 17,594
GST Rs. 3,166
TOTAL AMOUNT Rs. 20,760

Medical Declaration:
Have you or any member of your family proposed to be insured, suffered or are suffering from any disease/ailment/adverse
medical condition of any kind especially Heart/Stroke/Cancer/Renal disorder/Alzheimer's disease/Parkinsons's disease

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No

Declaration:
I hereby declare, on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars
given by me are true and complete in all respects to the best of my knowledge and that I am authorised to propose on behalf
of these persons. I understand that the information provided by me will form the basis of the insurance policy, is subject
to the Board approved underwriting policy of the insurance company and that the policy will come into force only after full
payment of the premium chargeable. I understand that acceptance of the proposal is subject to evaluation of the proposal
by Company's medical team I further declare that I will notify in writing any change occurring in the occupation or general
health of the person proposed for insurance after the proposal has been submitted but before communication of the risk
acceptance by the company. I declare that I consent to the company seeking medical information from any doctor or hospital
who/which at any time has attended on the person to be insured or from any past or present employer concerning anything
which affects the physical or mental health of the person to be insured and seeking information from any insurer to whom
an application for insurance on the person to be insured has been made for the purpose of underwriting the proposal and/or
claim settlement. I authorize the company to share information pertaining to my proposal including the medical records of the
person to be insured for the sole purpose of underwriting the proposal and/or claims settlement and with any Governmental
and/or Regulatory authority.

Prohibition of Rebates: (Section 41 of the Insurance Act): No person shall allow or offer to allow either directly or indirectly
as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relation to lives
or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on
the policy, nor shall any person taking out or renewing or continuing a policy accept rebate, except such rebate as may be
allowed in accordance with the published prospectuses or tables of the insurer.

Any person making default in complying with the provision of this section shall be liable for a penalty which may extend to ten
lakh rupees.
I also confirm that the source of funds for premium paid under this policy is legal.

I hereby agree and confirm that:

- The premium is paid for purchase of insurance policy through net banking account or credit/debit card issued in my name,
i.e. proposer/policyholder.
- And all premium has been paid from genuine sources and no premium has been paid out of proceeds of crime related to any
of the scheduled offences listed in Prevention of Money Laundering Act, 2002. I understand that the Company has the right to
call for documents to establish sources of funds. The company has right to cancel the insurance contract in case I am found
guilty by any competent court of law directly or indirectly governing prevention of money laundering in India.

Authenticated through OTP at 2018-10-06 10:28:02.0

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