RENEWAL PREMIUM RECEIPT

TOTAL

From 01/07/2015 to 01/07/2016

Mr. Saurabha Nayak

21/07/2015 96103682 12133707 105L055V01 10000.00 0.00

0.0010000.00

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# UIN-Unique Identification NO. Specified by IRDAI.*For Ulip Policies,Service Tax and Education Cess are deducted by way of cancellation of Units.**The amount indicated as balance in deposit(if any) will be adjusted towards future premium. No interest will be payable on Balance in Deposit

CONSOLIDATED REVENUE STAMP DUTY PAID : NOTIFICATION NO - MUDRANK 0715/0000425968201516/CR-322/M1-05/05/2015

Receipt Number

Policy Number

Product Name / Riders PremiumAmount

Rs.

Reinstatement Amount

Rs.

Balance in Deposit**

Rs.

Receipt Date

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Service Tax*Rs.

Education Cess*Rs.

LifeTime Super Pension

UIN#

C/o Chhayakanta NagarHouse Of K. M. SahobAt Balighat Puri

PuriOrissa

..

752002