FAMILY HEALTH OPTIMA INSURANCE POLICY - SCHEDULE
Policy No. : P/700002/01/2023/007530 Previous Policy No. :
Proposer's Code : 3629867 Issuing Office Code : 700002
Proposer's Name : SIDDHARTHAN M A Issuing Office Name : Online Business
Address : PLOT NO.9, VGN SUMMERDALE Address : No:111-112,Gokul Arcade-A 1st Floor
PHASE -2, QUEEN STREET, Sahar Road Vile Parle(East)
KOVUR. Mumbai - 400057
ONLINE BUSINESS
Tamil Nadu,Chennai-600122
Phone No : 8939007001 Toll Free No : 1800-425-2255
E-mail id :
[email protected] E-mail id :
[email protected]Proposal date : 02/07/2023 Fulfiller Code : SO700002 Sector : Urban
Date of Inception of first policy : 03/07/2023
Intermediary Code : OL0000000004
Renewal Year : NEW
Receipt No : 1272007864 Name : Tamil Nadu Telesales
Receipt Date : 02/07/2023
Premium : Rs 37,800.00 /- Service Tax : Rs 4,669.00 /- Phone No : /
Stamp Duty : Re 1.00 /- Total Premium : Rs 42,470.00/- :
E-mail id NIL
Total Premium In Words : Rupees Forty Two Thousand Four Hundred and Seventy Only
PERIOD OF INSURANCE FROM : 03/07/2023 00:00:00 TO : Midnight Of 02/07/2024
SCHEME - DESCRIPTION : 2 ADULTS + 1 CHILD BASIC FLOATER SUM INSURED : Rs 1500000 /- ( Fifteen Lakhs Only)
.
LIMIT OF COVERAGE : Rs.1500000 /- Bonus : Rs /-
.
Details of Insured Persons :
Sl. Name of the Insured Sex Date of Birth Age-Yrs/Mths Relationship with Pre Existing Disease/s ID Card No
No. Proposer
1 SIDDHARTHAN M A MALE 13-03-1994 29 Yrs 4 Mths SELF NONE 3629867-1
2 KOUSALYA M FEMALE 04-07-1997 25 Yrs11 Mths SPOUSE NONE 3629867-2
3 VIYAN K S MALE 29-04-2021 2 Yrs 3 Mths DEPENDANT NONE 3629867-3
CHILD
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: [email protected] Fax No: 1800 425 5522.
In the event of the policy being withdrawn in future, intimation about the withdrawal will be sent 3 months prior to the date when renewal falls
due.The insured will have the option of migrating to any other similar health insurance policy offered by the Company at the relevant time.
Continuity of benefits for waiting period and bonus, if any and if applicable, will be given provided the insured had been renewing the policy
without any break (or renewing within the grace period offered)
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Online Business
on 02nd Day of July 2023.
Entered By : STAR_PORTAL For Star Health and Allied Insurance Company Ltd.
This is an electronically
IRDA Regn. No 129 generated document(Policy
Schedule). "Consolidated stamp
paid vide certificate
Corporate Identity Number U66010TN2005PLC056649
No.CSD/33/2023/2177
Email ID : [email protected] Dt.17/07/2023" Authorised Signatory
Kannan S
CN=Kannan S,
SERIALNUMBER=f29a5b3b9c6f48e2841a06abb56c43b5ab5
647325765c9667cc1b11bd05622a2, 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: 2014.07.02 11:33:55 IST
Attached to and forming part of Policy No. P/700002/01/2023/007530
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
paid vide certificate
No.CSD/33/2023/2177
Dt.17/07/2023" Authorised Signatory
Hospitalisation Benefit Policy
Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986
Policy No : P/700002/01/2023/007530 Type Of Policy : FHO-Policy
Issue Office : 700002 - Online Business
Address : No:111-112,Gokul Arcade-A 1st Floor
Sahar Road Vile Parle(East)
Mumbai - 400057
Toll Free No : 1800-425-2255
Email :
[email protected]This is to certify that SIDDHARTHAN M A has paid Rs 42470 (Total Premium In Words : Indian Rupees Forty Two Thousand
Four Hundred and Seventy Only) towards Premium for Hospitalization Insurance vide Policy No: P/700002/01/2023/007530
for the Period 03-JUL-23 To 02-JUL-24 issued on 02-JUL-23 .
Payment received by Cheque/Credit/Debit Card vide collection No:
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
Family Health Optima
Following values are the details entered to obtain your Family Health Optima policy
Proposer Details
This section contains proposer details
Name : SIDDHARTHAN M A Mobile: 8939007001
Address: PLOT NO.9, VGN SUMMERDALE PHASE-2, Email:
[email protected] QUEEN STREET, KOVUR.
Tamil Nadu,Chennai-600122
PAN: GHFPS3885B
Plan Details
This section contains the Plan and Policy Details
Policy Start Date: 03-07-2023 Policy End Date: 02-07-2024
Policy Period: From 03/07/2023 00:00:00 to Midnight Of 02/07/2024
Insured Details
The Section contains the details of all Nominated Members to be covered in the policy
Insured 1
Insured Name : SIDDHARTHAN M A
Gender : MALE
Date of Birth : 13-03-1994
Relationship to the Proposer : SELF
Pre Exisiting Disease : NONE
Insured 2
Insured Name : KOUSALYA M
Gender : FEMALE
Date of Birth : 04-07-1997
Relationship to the Proposer : SPOUSE
Pre Exisiting Disease : NONE
Insured 3
Insured Name : VIYAN K S
Gender : MALE
Date of Birth : 29-04-2021
Relationship to the Proposer : DEPENDANT CHILD
Pre Exisiting Disease : NONE
Whether any of the Insured Members covered in the policy has suffered/advised treatment for any
of the following diseases:
a. Cancer - No
b. Chronic Kidney Disease - No
c. Brain Stroke\CVA - No
d. Parksinsons Disease - No
e. Alzehimers's Disease - No
f. Renal Complications - No
g. Heart Diseases - No
Social Status : No
Premium Calculation
Cover Description Sum Insured Premium
Base Cover 1500000 37800
TOTAL PREMIUM 37800
STAMP DUTY 1
ADD :SERVICE TAX 4669
TOTAL AMOUNT 42470
Declaration
I hereby confirm that all the above information is true and correct according to my belief.I also agree that my policy
is for cancellation in case any of the above entered information is found to be false/intentionally misrepresented.
Note: Acceptance of Risk in case of persons suffering from any disease/ailments is subject to evaluation by our
Medical Team
