Family Health Optima Insurance Plan

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

Policy Schedule
Policy No. : P/161121/01/2018/000626 Previous Policy No. : AMB0000345000100
Customer Code : AA0004981185 Issuing Office Code : 161121
Customer Name : Mr.ANIL MITTAL Issuing Office Name : Branch Office - Noida
Proposer's Code : 6963564
Proposer's Name : Mr.ANIL MITTAL
Address : R-24 , SATABDI NAGAR Address : Office No-606/607
MEERUT 6th Floor, P3, Krishna Apra Plaza,
U.P Sector-18, Noida-201301
Meerut,Meerut,Uttar Pradesh-250002

Phone No : ./9212213776/ Phone No : 0120 - 6518434 - 40

E-mail id : . E-mail id : noida@starhealth.in
Proposal date : 22/04/2017 Fulfiller Code : SH26325
Date of Inception of first policy : 25-APR-17
Renewal Year : NEW
Intermediary Code : BA0000273882
Receipt No : 1165000664 : Mr.MAYANK KAINTHOLA
Name
Receipt Date : 22/04/2017
Phone No : 9999000714/9999000714
Premium : Rs 15790 /- Service Tax : Rs 2369 /-
Stamp Duty : Re 1 /- Total Premium : Rs 18159 /- :
E-mail id mayank.kainthola@gmail.com
Total Premium In Words : Rupees Eighteen Thousand One Hundred Fifty Nine Only
PERIOD OF INSURANCE FROM : 25/04/2017 00:00:00 TO : Midnight Of 24/04/2018
SCHEME - DESCRIPTION : 2 ADULTS + 3 CHILDREN BASIC FLOATER SUM INSURED : Rs. 500000
In Words: Five Lakhs Only
Bonus : Rs 0
.
Limit of coverage : Rs. 500000 Recharge Benefit : 150000

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 LAKSHY KUMAR MITTAL M 06/03/1995 22 Yrs DEPENDANT 6963564-4 No PED declared
1 Mths CHILD
1 YOGANSHI MITTAL F 16/06/2000 16 Yrs DEPENDANT 6963564-5 No PED declared
10 Mths CHILD
1 DIVYA KUMAR MITTAL M 23/11/1993 23 Yrs DEPENDANT 6963564-3 No PED declared
5 Mths CHILD
1 SARITA MITTAL F 07/10/1971 45 Yrs SPOUSE 6963564-2 No PED declared
6 Mths
1 ANIL MITTAL M 02/04/1969 48 Yrs SELF 6963564-1 No PED declared
0 Mths

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.
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.

Entered By : SH13353 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 3
 Attached to and forming part of Policy No. P/161121/01/2018/000626
Sector Classification

Urban

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

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 SARITA MITTAL Spouse 46 100

Continuity Benefits applicable is as follows

30 Days First Two Year

S.No. Name Of the Id card No 1st Year Pre Existing Disease
Waiting Period Exclusion
Insured Exclusions

1 LAKSHY KUMAR 6963564-4 Waived Not Waived Covered

MITTAL Applicable

1 YOGANSHI 6963564-5 Waived Not Waived Covered

MITTAL Applicable

1 DIVYA KUMAR 6963564-3 Waived Not Waived Covered

MITTAL Applicable

1 SARITA MITTAL 6963564-2 Waived Not Waived Covered

Applicable

1 ANIL MITTAL 6963564-1 Waived Not Waived Covered

Applicable

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Noida on 24th
Day of April 2017.

Entered By : SH13353 For Star Health and Allied Insurance Company Ltd.

Authorised Signatory
2 of 3
 Star Health and Allied Insurance
Company Limited
Emergency Help Line No. 1800 425 2255 / 044 - 2831 9100
e-mail : support@starhealth.in Website : www.starhealth.in Customer Identity Card

Please quote the Customer Id No. for assistance Customer ID No. : 6963564-4
This Card is valid until otherwise Cancelled. Name : LAKSHYA MITTAL
This ID Card is invalid, if the insurance cover is not in force. Date Of Birth : 06-MAR-95 Age : 22 Years
Immediate intimation to 'Star' through above Tel Nos. is a must
Gender : Male Office Code : 161121
in case of Hospitalisation.
At the time of hospitalization, kindly submit any Government Valid From : 25-APR-17 TA/SSM/SM Code : SH26325
approved photo ID Card. Agent/Broker/TE Code : BA0000273882
Corporate Identity Number: U66010TN2005PLC056649 IRDAI Regn. No:129

Star Health and Allied Insurance Star Health and Allied Insurance
Company Limited Company Limited

Customer Identity Card Customer Identity Card

Customer ID No. : 6963564-5 Customer ID No. : 6963564-1

Name : YOGANSHI MITTAL Name : ANIL MITTAL
Date Of Birth : 16-JUN-00 Age : 16 Years Date Of Birth : 02-APR-69 Age : 48 Years
Gender : Female Office Code : 161121 Gender : Male Office Code : 161121
Valid From : 25-APR-17 TA/SSM/SM Code : SH26325 Valid From : 25-APR-17 TA/SSM/SM Code : SH26325
Agent/Broker/TE Code : BA0000273882 Agent/Broker/TE Code : BA0000273882
IRDAI Regn. No:129 IRDAI Regn. No:129

Star Health and Allied Insurance Star Health and Allied Insurance
Company Limited Company Limited
Customer Identity Card Customer Identity Card

Customer ID No. : 6963564-2 Customer ID No. : 6963564-3

Name : SARITA MITTAL Name : DIVYA KUMAR MITTAL
Date Of Birth : 07-OCT-71 Age : 45 Years Date Of Birth : 23-NOV-93 Age : 23 Years
Gender : Female Office Code : 161121 Gender : Male Office Code : 161121
Valid From : 25-APR-17 TA/SSM/SM Code : SH26325 Valid From : 25-APR-17 TA/SSM/SM Code : SH26325
Agent/Broker/TE Code : BA0000273882 Agent/Broker/TE Code : BA0000273882

IRDAIIRDAI
Regn. Regn.
No:129No:129 IRDAIIRDAI
Regn. Regn.
No:129No:129

*This is a temporary ID card issued along with the policy. Original ID cards will be dispatched shortly.

Entered By : SH13353 For Star Health and Allied Insurance Company Ltd.

Authorised Signatory
3 of 3