Star Health and Allied Insurance Company Limited

Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road,

Nungambakkam, Chennai – 600034.

Phone : 044 – 28288800 Telefax : 044 – 28260062 Website : www.starhealth.in

IRDA Registration No : 129; Corporate Identity Number : U66010TN2005PLC056649

Sheet attached to and forming part of the Proposal Form

(for Health / Personal Accident / Overseas Travel Insurance)

Name of the Proposer
Details of the Bank Account
Name of the Bank
Name of the Branch of the Bank
Type of Account / SB Account / Current Account / Others (please specify)
Account Number
IFSC Code no.of the Branch

Further, please attach a photo copy of cancelled cheque leaf of the above Bank Account.

Date :

Place : Signature of the Proposer

Circular No . Corp / Underwriting / Tech / General / 2014-15 / 020 Dated 25.09.2014