Collecting Branch : EPS1 Servicing Branch : 92B

E-mail : bo_eps1@licindia.com LIC of India,Ambarnath Br Office

Phone : +91-022-1251 First Floor Panvelkar Plaza
Opp. D N S Bank Station Road Ambernat
Transaction No. : PR0351045900041011 (East)
Ambernath
Date ( Time ): 13/01/2011 ( 18:25:41 ) 421501

RENEWAL PREMIUM RECEIPT

Received with thanks Rs. 25317.00 through Payment Gateway over the Internet from:

Smt./Ms./Shri : Chirag Yashwant Patil

Towards the following

Policy No Plan Inst. Prem(Rs) No Of Inst Total Premium Branch

Name Term Mode Due Fr Late Fee Next Due
Agency Code D.O.C. Sum Assured Due To Total Amt
924597325 103 5,020.00 1 5,020.00 92B
Patil Cy 21 YLY 12/10 0.00 12/11
0083492B 27/12/2008 1,00,000.00 12/10 5,020.00
924597326 149 5,102.00 1 5,102.00 92B
Patil Cy 78 YLY 12/10 0.00 12/11
0083492B 27/12/2008 1,00,000.00 12/10 5,102.00
924597327 107 8,856.00 1 8,856.00 92B
Patil Cy 20 YLY 12/10 0.00 12/11
0083492B 27/12/2008 1,00,000.00 12/10 8,856.00
924597328 75 6,339.00 1 6,339.00 92B
Patil Cy 20 YLY 12/10 0.00 12/11
0083492B 27/12/2008 1,00,000.00 12/10 6,339.00
Page Total (Rs) 25,317.00 25,317.00
0.00
25,317.00
Grand Total (Rs) 25,317.00 25,317.00
0.00
25,317.00

RUPEES TWENTY-FIVE THOUSAND THREE HUNDRED SEVENTEEN ONLY

Chirag Yashwant Patil A.Mu.Sh.2010/1304/CR 324/M 1 Dated 23/06/2010

402 Mint Motiram Garden,
Ambernath E
421501

This receipt is electronically generated and is digitally signed.

Signature Not Verified
Digitally signed by REKHA VARSHNEY
Date: January 15, 2011 12:08:44 PM IST
Reason: Premium Receipt
Location: LIC OF INDIA

Zindagi Ke Saath Bhi, Zindagi Ke Baad Bhi

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