Collecting Bank: CSC eGovernance Services India Ltd.

Branch Code: CBK1

Branch Code : CSC250611890012
PCMC,Network Operating Center,
Reciept No. : 3095389
1st Floor,Jeevan Seva Annexe,
Date: 2021-01-30 19:10:45
S.V.Road,Santacruz(W), Mumbai-400054
Ref. No.: LICI2021000166309684
SMS: LICHELP "Policy Number" to 9222492224
CSC Ref. No.: 1030191026835046
Phone: +91-022-1251
Email: bo_cbk1@licindia.com
GSTN: N

RENEWAL PREMIUM RECIEPT

Received With Thanks Rs. 7,778.04 Through CSC EGovernance Services India Ltd. , Retailer ID: 250611890012
Policy Holder: Shri/Smt. Bhagwan Sah
towards the following policy

CGST Branch
Plan Inst. Premium No. of Inst. Total Premium
Policy No.
SGST/UTGST Next Due
Term Mode Due From Late Fee
Name
Total Amt (Rs) Reg. No.
D.O.C Sum Assured (Rs) Due To CDA Charges
Agency Code

529806038 7,431.00 1 7,431.00 26.47 51B

Bhagwan Sah Yearly 28/08/2020 294.10 26.47 28/08/2021

28/08/2020 0.00 52.94 10AAACL0582H2Z0

7,431.00 26.47
Page Total (Rs) 7,431.00 294.10 26.47
0.00 52.94

7,431.00 26.47
Grand Total (Rs) 7,431.00 294.10 26.47
0.00 52.94

In Words (Rupees) : Seven Thousand, Seven Hundred Seventy-Eight Rupees And Four Paise

Mudrank No.: CSD/113/2020/1936 DTD. 18 SEP 2020

Retailer Signature
Retailer ID : 250611890012
Prem Kumar

LIC PREMIUM PAYMENT FACILITY IS FREE OF COST. POLICY HOLDERS NEED NOT TO PAY ANY EXTRA AMOUNT AS SERVICE CHARGE OF
RETAILER/FRANCHISEES

Retailer : CSC e-Governanace Services India Ltd. 238, Okhla Industrial State, Phase-III, New Delhi-110020
Computer generated receipt. Receipt validity subject to payment realization.
PRINTED ON | 30-01-2021 19:10:47