Branch Office - Noida Office No-606/607 , 6th Floor, P3, Krishna Apra Plaza, , Sector-18, Noida-201301 , , 201301

Advance Premium Receipt

Customer Code : AA0004813997 Receipt No : 9L165Y19R0000535

Received from : Mr.ANKIT NATH SAXENA Receipt Date : 08/03/2019

Customer Address : B - 14/01 , HIMGIRI APARTMENT Collection No : 11-01/1165019628

SEC. - 34 Collection Date : 08/03/2019

NOIDA Office Code : 161121 - Branch Office - Noida

Supplier GSTIN : 09AAJCS4517L1ZW

Customer GSTIN : - Place of Supply : - State Code: -

Amount Collected : Rs. 22550 /- Inclusive of tax : CGST @9%- Rs. 1720/- SGST/UTGST @9%- Rs. 1720

Amount in words : Indian Rupees Twenty-Two Thousand Five Hundred Fifty Only SAC code : 997133

Towards the Following : PREMIUM RECEIPT ONLINE POLICY

S. No. Proposal Ref. No Fulfiller Code Intermediary Code Amount Collected Mode of Pay Bank Name CHQ/CC/DD No CHQ/DD/BC Dt

1 R/161121/01/2019/019869 SH24807 SD161121 22550 CC BANK 190308351660 08/03/2019

055767

For Star Health and Allied Insurance Co. Ltd

Note : Receipt Subject to realization of Cheque / DD

This is only an evidence of receipt of money by the company
Risk will commence once the proposal is examined and accepted Authorised Signatory

Amount of Tax Subject to reverse Charge : No

CN=SRINIVASAN RAMASWAMY,

SRINIVASAN SERIALNUMBER=91fa1f6086f94760c8858bf1d653fa94cf9b2caaf7d01
926c03552012536da26,
OID.2.5.4.20=b9b82e818a1c0f85a0f74b8e131a80293ef1084f20a913bd
c1f47ed182afbf8c, ST=Tamil Nadu, OID.2.5.4.17=600034, OU=CHIEF

RAMASWAMY FINANCIAL OFFICER, O=STAR HEALTH AND ALLIED INSURANCE

COMPANY LIMITED, C=IN. Date :Fri Mar 08 19:45:25 IST 2019

IRDA Regn. No 129 Corporate Identity Number U66010TN2005PLC056649 Email id : info@starhealth.in

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No:1800-425-5522 Toll Free No:1800-425-2255 / 1800-102-4477,CIN
:U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129