Family Health Optima Insurance Plan

Unique Identification No.IRDA/NL-HLT/SHAI/P-H/V.II/129/14-15

Policy Schedule
Policy No. : P/161211/01/2017/006536 Previous Policy No. : P/161211/01/2016/004777
Customer Code : AA0001210536 Issuing Office Code : 161211
Customer Name : SUDESH KUMAR Issuing Office Name : Branch Ofifce - Pitampura
Proposer's Code : 2682848
Proposer's Name : SUDESH KUMAR
Address : RZ-26P/181,Gali No.37, 3rd Address : Unit No:709 - 710, 7th Floor, GD
Floor,Flat No. 215 ITL North Tower,
Indra Park, Palam Colony, New Delhi A - 09, Netaji Subhash Palace,
Pitampura, New Delhi - 110034.
Delhi Cantt. (Part),South West,Delhi-
110045
Phone No : NIL/9810571593/ Phone No : 011- 45261811 / 18
E-mail id : NIL E-mail id : pitampura@starhealth.in
Proposal date : 17/01/2013 Fulfiller Code : SH13789
Date of Inception of first policy : 17-JAN-13
Renewal Year : Fourth Year
Intermediary Code : BA0000135190
Receipt No : 1214007540 :
Name Mr.SANDEEP CHAUHAN
Receipt Date : 16/01/2017
Phone No : 9999956891/9891697773
Premium : Rs 10695 /- Service Tax : Rs 1604 /-
Stamp Duty : Re 1 /- Total Premium : Rs 12299 /- :
E-mail id sandeepchauhan14@gmail.co
m
Total Premium In Words : Rupees Twelve Thousand Two Hundred Ninety Nine Only
PERIOD OF INSURANCE FROM : 17/01/2017 00:00:00 TO : Midnight Of 16/01/2018
SCHEME - DESCRIPTION : 2 ADULTS + 2 CHILDREN BASIC FLOATER SUM INSURED : Rs. 300000
In Words: Three Lakhs Only
Bonus : Rs 90000
.
Limit of coverage : Rs. 390000 Recharge Benefit : 75000

Details of Insured Persons :

Sl. Name of the Insured Sex Date of Birth Age- Relationship with ID Card No Pre Existing Disease/s
No. Yrs/Mths Proposer
1 SUDESH KUMAR M 08/04/1980 36 Yrs SELF 2682848-1 No PED declared
9 Mths

2 SANGEETA CHAUHAN F 28/08/1983 33 Yrs SPOUSE 2682848-2 No PED declared

4 Mths

3 STUTI F 06/05/2012 4 Yrs 8 DEPENDANT 2682848-3 No PED declared

Mths CHILD

4 SHIVANYA F 24/02/2016 0 Yrs DEPENDANT 2682848-4 No PED declared

10 Mths CHILD

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).
Expenses relating to the hospitalisation will be considered in proportion to the room rent stated in the policy.

Entered By : SH38887 For Star Health and Allied Insurance Company Ltd.
IRDAI Regn. No 129

Corporate Identity Number U66010TN2005PLC056649

Email ID : info@starhealth.in Authorised Signatory
1 of 2
 Attached to and forming part of Policy No. P/161211/01/2017/006536
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.
Sector Classification

Urban

Toll Free No : 1800 425 2255 Email: support@starhealth.in, Fax No: 1800 425 5522.
Nominee Details:

Insured Name: SUDESH KUMAR

Sr. Nominee Relationship Percentage Appointee Appointee Appointee

Nominee Name Age
No Name Age Relationship

Insured Name: SANGEETA CHAUHAN

Sr. Nominee Relationship Percentage Appointee Appointee Appointee

Nominee Name Age
No Name Age Relationship

Insured Name: STUTI

Sr. Nominee Relationship Percentage Appointee Appointee Appointee

Nominee Name Age
No Name Age Relationship

Insured Name: SHIVANYA

Sr. Nominee Relationship Percentage Appointee Appointee Appointee

Nominee Name Age
No Name Age Relationship

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Ofifce - Pitampura on
16th Day of January 2017.

Entered By : SH38887 For Star Health and Allied Insurance Company Ltd.

Authorised Signatory
2 of 2