*This form is to be printed, signed and uploaded back to submit the Premier Service Registration request.

Premier Services

Name Date of Birth Aadhaar No/UID

Pushpa Saxena 30/06/1965

Mobile Number Email ID PAN

98******34 sh********58@gmail.com

Passport Number

Eligible Policies for Premier Services

Name Policy Number Date of Birth Premium (`)

Pushpa Saxena 241581508 30/06/1965 1,992.00

* I have read the provisions contained in the "Terms of Service: Registration for LIC's Premier Services"and accept
them. I agree that all transactions executed over LIC's web-site: www.licindia.in under my User-ID and Password
will be binding on me.

Signature