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

2015-2016 DATE OF ISSUE: 12/02/2013

This is to certify that the following premium have been received under the following
life insurance by Mr. Shoeb Ahmed Siraj Ahmed Ansari

Name Mr. Shoeb Ahmed Siraj Ahmed Ansari

Policy Number 31L2-000104226/44/00/000
Plan 75(The Money Back Policy – 20 Years)
Policy Term 20
Premium Paying Term 20
Commencement Date 28/06/2013
Instalment Premium 70,205.00
Mode of Premium Payment YLY
Reference Code

Due Due To Numbers of Premium Amount Received Collecting Status

From Instalments Received Date Branch
06/2015 06/2015 1 70,205.00 11/06/2015 60B Normal

Total amount received towards premium for the policy number

Is Rs. 70,205.00 for the financial year 2015-2016