Payment Receipt

Policy Number: Name: Address: 792724577 VIMAL K DIMRI Date and Time: Base Life Insured: 02/03/2012 04:57PM VIMAL K DIMRI AJPR11112AA052

119/215 Sector-11 Block-119 Reference Number: Agrawal Farm Ward No-13 Jaipur 302020 Your Agent Advisor:

DirectCustomer Services 100587

Tel.No.

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Agent Code:

Dear VIMAL K DIMRI, Thank you for being part of the Max New York Life Family. This is to acknowledge the receipt of monies towards the payment reason- Renewal Premium as per the details below. Cheque/DD/Reference No 269912 Cheque/DD/Ref. Date 04/03/2012 Bank Name Uco Bank Policy Amount (Rs.) 12000.0

We value your patronage and are committed to providing you the best in class service. Should you need any further assistance, please call our Customer Help Line - 1800 200 5577 (Toll free from any network). You can also email at service.helpdesk@maxnewyorklife.com. Your Sincerely, for Max New York Life Insurance Co. Ltd. Authorized Signatory Note:

In case premium for Unit Linked Insurance policies is received in Max New York Life designated offices vide cash, local cheques & local demand drafts before 3:00 PM , Net Asset Value (NAV) of the same day will be applicable ; in case premium is received after 3:00 PM, the NAV of the next business day will be applied . In case of premium received vide outstation cheques / demand drafts, the NAV of the business day on which such cheques / demand drafts are realised & credited in Company's account will be applied. If the payment has been made other than in cash, this receipt is conditional upon the credit in Company's account, post clearance of the instrument / facility including electronic mode. Monies received would be adjusted against the due premium as per the policy contract. In case policy status is lapsed, the risk coverage is subject to the reinstatement of the policy as per terms and conditions of the plan opted. Final receipt would be sent to you after adjustment of monies as per the policy terms & conditions. Benefit under Section 80C / 80CCC / 80D of Income Tax Act, 1961 would be available as applicable. Service Tax which is applicable on the risk cover & fund related charges under Section 65 (105) (zx) of Finance Act 1994, as amended by Finance (No.2) Act 2004 and Section 65 (105) (zzzzf) of Finance Act 2008, is deducted from the funds at the applicable rates. Benefit under Section 80C/ 80CC / 80D of Income Tax, 1961 would be available as applicable. Service Tax is payable on risk premium/mortality charges and on other charges, as applicable. The Policyholder shall be required to pay Service Tax, Education Cess or any other form of taxes or charges or levies as applicable under laws and regulations and as per Company's prevalent policy. Tax laws are subject to change from time to time. For Max Vijay policies please contact us through E-mail: helpdesk@maxvijay.com,Phone(Tollfree):1800-419-4194 (Monday to Saturday 9:30 am to 6:30 pm)
Version No. Apr-08/1.2

E.&O.E

MAX NEW YORK LIFE INSURANCE CO. LTD.

Operations Center, 90-A, Udyog Vihar, Sector 18, Gurgaon-122 015 Haryana Service Tax Registration No. 443 / ST / DIV - III / GGN / 02 Registered Office: Max House,3rd Floor, 1 Dr Jha Marg, Okhla, New Delhi 110 020, India