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Max New York Life Insurance Co.

Ltd Operation center, 90-A, Udyog Vihar, Sector 18, Gurgaon -- 122015 Customer Help Line -1800 200 5577 (Toll free from any network) Regd Office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi 110 020, India Visit us at: www.maxnewyorklife.com E-mail: service.helpdesk@maxnewyorklife.com

www.maxnewyorklife.com

Premium Paid Certificate for the Period 31/05/2011 to 29/02/2012


Policy Number: Name: Address: 700946353 Mr. Pramod Kumar Pandey H NO-524 GALI NO-6, LAHPAT COLONY-2 MEETHAPUR EXTN. .,Badarpur New Delhi - 110044 9891496433, 011-26667156-undefined As on Date Base Life Insured: Your Agent Advisor: Agent Code Your Agent Phone No General Office 29-Feb-2012 Mr. Pramod Kumar Pandey Mr. Yogesh Saxena 162905 011-25250404 Agency Channel GO - Delhi 5

Telephone

Dear Mr. Pramod Kumar Pandey, Thank you for being part of the Max New York Life family. This is to acknowledge receipt of your premium for the period 31/05/2011 to 29/02/2012 as per details below. We also take this opportunity to reiterate that we value your patronage and are committed to providing you the best in class service.

Yours Sincerely, for Max New York Life Insurance Co. Ltd.

Authorized Signatory

Plan

Annual Target Premium Received / Top Up# (Rs.) 36,000.00 36,000.00

Current Frequency

Effective Date of Coverage

Benefit Under Income Tax Act 1961, if applicable U/S 80C

Max New York Life Flexi Fortune (10 Pay) Total Note:

Semi-annual

31-May-2011

The total premium amount is inclusive of Service Tax if paid. This certificate is a consolidation of the individual premium receipts sent to you. Subject to realisation of monies

URM23 V1.3 27062011

29-Feb-2012

E.&O.E.

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