Life Insurance Corporation of India

PCMC, Network Operating Center

1st Floor, Jeevan Seva Annexe

S.V.Road, Santacruz(W)

Mumbai - 400 054

PREMIUM PAID CERTIFICATE FOR THE YEAR 2014-2015

DATE OF ISSUE: 19/02/2015

This is to certify that the following premium have been received under the

following life insurance policy held by Rajankumar Bishambharprasad

Gupta

Name Rajankumar Bishambharprasad Gupta Policy Number 894048660

Plan 165(Jeevan Saral) Policy Term 20 Premium Paying Term 20 Commencement Date 07/12/2009 Instalment Premium 2,042.00 Mode Of Premium Payment MLY Reference Code 87733440

Due From Due To Number Of

Instalments

Premium Amount Received

Received Date

Collecting Branch Status

04/2014 04/2014 1 2,042.00 07/04/2014 E089 Normal 05/2014 05/2014 1 2,042.00 07/05/2014 E089 Normal 06/2014 06/2014 1 2,042.00 07/06/2014 E089 Normal 07/2014 07/2014 1 2,042.00 07/07/2014 E089 Normal 08/2014 08/2014 1 2,042.00 07/08/2014 E089 Normal 09/2014 09/2014 1 2,042.00 08/09/2014 E089 Normal 10/2014 10/2014 1 2,042.00 07/10/2014 E089 Normal 11/2014 11/2014 1 2,042.00 07/11/2014 E089 Normal 12/2014 12/2014 1 2,042.00 08/12/2014 E089 Normal 01/2015 01/2015 1 2,042.00 08/01/2015 E089 Normal 02/2015 02/2015 1 2,042.00 07/02/2015 E089 Normal

Total amount received towards premium for the policy number

894048660 is Rs. 22,462.00 for the financial year 2014-2015

This certificate is electronically generated