Collecting Branch : EPS1 Servicing Branch : LIC of India, Hyderabad

City Branch Office No-V

Transaction No : 16525471
Jeevan Jyothi 5-9-57 (Iii
Date ( Time ): 28/10/2019 ( 16:16:48 ) Hyd-Cbo-5,500029
bo_eps1@licindia.com
Receipt No : PR1652547100011920
HelpDesk: +91-022-1251

RENEWAL PREMIUM RECEIPT

Received with thanks ` 3,340.00 through Payment Gateway over the Internet from:

Smt./Ms./Shri : Gorty Suseela

towards the following :

Policy No Plan Inst. Premium No Of Inst Total Premium CGST Branch

Name Term Mode Due From Late Fee SGST/UTGST Next Due
Agency Code D.O.C. Sum Assured Due To CD Charges Total Amt Reg. No.
(`) (`) (`)
641026884 174 3,340.00 1 3,340.00 0.00 650
Gorty Suseela 16 HLY 09/19 0.00 0.0 03/20
01337657 28/03/2006 1,00,000 09/19 0.00 3,340.00 0

Page Total (`) 3,340.00 3,340.00 0.00

0.00 0.00
0.00 3,340.00
Grand Total (`) 3,340.00 3,340.00 0.00
0.00 0.00
0.00 3,340.00

GST borne by LIC of India ` 75.16

THREE THOUSAND THREE HUNDRED FORTY RUPEES AND ZERO PAISE ONLY

Gorty Suseela
H.No.4-1/2 Plot No 15,Kanchan Bagh,
Sam Reddy Sami Reddy Clyn,
Almas Guda,Hyderabad

500058 Payment Acknowledgement generated through

Online Portal on 28-Oct-19 Time : 16:19:51.
Mobile: 8374573231
Email: s8374573231@gmail.com

This receipt is electronically generated and no signature is required.

Har Pal Aapke Saath!