Branch Office - R S Puram Obli Towers" Milky White Apartments , No : 594, Rathnasabapathy Road, (DB Road), , RS Puram,

Coimbatore - 641002. , COIMBATORE , 641002

Advance Premium Receipt
Customer Code : AA0007072363 Receipt No : 33B514Y20R000542

Received from : Mrs.T BABITHA Receipt Date : 31/05/2019

Customer Address : 26 / 7,SUBBIAH NAGAR,PERIYANAICKEN PALAYAM, Collection No : 11-01/1514001101

SRI RAMAKRISHNA VIDHAYALAYA, Collection Date : 31/05/2019

COIMBATORE - 641020 Office Code : 121126 - Branch Office - R S Puram

Supplier GSTIN : 33AAJCS4517L1Z5

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

Amount Collected : Rs. 10998 /- Inclusive of tax : CGST @9%- Rs. 839/- SGST/UTGST @9%- Rs. 839

Amount in words : Indian Rupees Ten Thousand Nine Hundred Ninety-Eight 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/121126/01/2020/001447 SH20663 BA0000278226 10998 CC BANK 190531061771 31/05/2019

850605

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=PVS Lakshmiprasad,

PVS SERIALNUMBER=9e461d073974cff564ee9ba39dcb9f6c1b1fe484d
e3bff77fe99ff653e852cf9, ST=TAMIL NADU, OID.2.5.4.17=600034,
OID.2.5.4.20=3fbc716070e67ba3c9fed3530e1e3d7e9732722433b0
b08c8ac802f047aae330, OU=Technical, O=STAR HEALTH AND

Lakshmiprasad ALLIED INSURANCE COMPANY LIMITED, C=IN. Date :Fri May 31

10:15:06 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