Collecting Branch : EPS1 E-mail : bo_eps1@licindia.com Phone : +91-022-1251 Transaction No.

: PR0542429800011314 Date ( Time ): 06/10/2013 ( 22:49:57 )

Servicing Branch : 11A LIC of India, Janakpuri(New Delhi) B O B-1/10 Community Center Janakpuri New Delhi Janakpuri - Cbo 110058

RENEWAL PREMIUM ACKNOWLEDGEMENT

Received with thanks Rs. 631.80 through Payment Gateway over the Internet from: Smt./Ms./Shri : Gulshan Towards the following Plan Term D.O.C. 179 Gulshan G 20 7120411A 25/04/2011 Page Total (Rs) Policy No Name Agency Code 333246385 Inst. Prem(Rs) Mode Sum Assured 622.00 QLY 50,000.00 622.00 No Of Inst Due Fr Due To 1 07/13 07/13 Total Premium Late Fee 622.00 9.80 622.00 9.80 622.00 9.80 Service Tax Edu Cess Total Amt 0.00 0.00 631.80 0.00 0.00 631.80 0.00 0.00 631.80 Branch Next Due 11A 10/13

Grand Total (Rs)

622.00

RUPEES SIX HUNDRED THIRTY-ONE AND EIGHTY PAISE ONLY Gulshan H.No.7 W-48 T-Huts, Sultan Puri, New Delhi. 110086 110086 Payment Acknowledgement generated through Online Portal on 06-Oct-2013 Time : 22:52:03. Digitally Signed Premium Receipt sent by email

This receipt is electronically generated.

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