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Collecting Branch : EPS1 Servicing Branch : LIC of India, Surat City Branch
104-105, TRINITY BUSINESS
Transaction No : 15034117
MADHUVAN CIRCLE, ,ADAJAN
Date ( Time ): 30/07/2020 ( 19:42:46 ) Surat,395009
bo_eps1@licindia.com
Receipt No : PR1503411700012021
HelpDesk: +91-022-1251

RENEWAL PREMIUM RECEIPT

Received with thanks ` 766.00 through Payment Gateway over the Internet from:

Smt./Ms./Shri : Nitinbhai Mathurbhai Gohel

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
Revival D.O.C. Sum Assured Due To CD Charges Total Amt Reg. No.
(Yes/No) (`) (`) (`)
864099344 165 766.00 1 766.00 0.00 86R
Nitinbhai 31 QLY 07/20 0.00 0.00 10/20
No 22/07/2008 07/20 0.00 766.00 24AAACL0582H2ZR
62,500.00

Page Total (`) 766.00 766.00 0.00

0.00 0.00
0.00 766.00
Grand Total (`) 766.00 766.00 0.00
0.00 0.00
0.00 766.00

GST borne by LIC of India ` 17.24

SEVEN HUNDRED SIXTY SIX RUPEES AND ZERO PAISE ONLY

Nitinbhai Mathurbhai Gohel

103,Ashirwad Complex,
Jalaram Society,Kosad Rd.,
Amroli,Surat

390000 Payment Acknowledgement generated through

Online Portal on 30-Jul-20 Time : 19:44:06.
Mobile: 79******13
Email: dh********41@gmail.com

This receipt is electronically generated and no signature is required.

Har Pal Aapke Saath!