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3_(24/08/19)

HEALTH INSURANCE PREMIUM

Life Assured: Mr. Sadik Mohd Shaikh
Proposer: Mr. Sadik Mohd Shaikh
08-Ayesha Co-op H.S.C, Dr. Ansari Road
Near Noor Masjid, 2nd Rabodi
Thane (West), 400601,
Mumbai, Maharashtra,

Date of Receipt Policy Status UIN *

27/11/2020 In Force 116L056V78
Cheque Number Cheque Date Receipt Number Name of Bank
809872 25/11/2020 79393891 CITI BANK (CIT)
Policy Number Plan Name
04693648 ICICI Lombard Health Insurance
Due Date
Benefits Amount
From To
28/11/2020 27/11/2021 ICICI Lombard Health Insurance 25000.00

Total 25000.00

Tax benefits would be available as follows: Life Insurance Policy u/s 80c, *Interest on late payment will be charged
Pension Policy u/s 80CCC, Health Riders (if any) u/s 80D. Tax benefits @ 0.00 p.a. compounded half-yearly
would be as per prevailing Income Tax laws. Service Tax and Education
Cess extra as applicable. Servce Tax Details: Category of Service: Life Your next due date is : 28/11/2021
Insurance Service. Registration NO: MIV/ST/IAS-LIFE/1;
PAN BASED STC NO:AAACI7351PST001 Balance in Deposit 0.00

Mudrank No.: CONSOLIDATED REVENUE STAMP DUTY PAID : NOTIFICATION NO - MUDRANK0715/20716/CR-322/M1-26/08/2020

* UIN - Unique Identification No. Specified by IRDA.
If the payment has been made other than in cash, this receipt is conditional upon the credit in company's account post clearance of
the instrument/facility including electronic modes. This is a computer generated advice and does not require any signature.

Going Green - Committed to saving paper for a greener future: Effective Aug '19, customers on monthly premium paying
frequency will receive their printed receipts on a quarterly basis. The monthly receipts will be emailed to the registered em ail id
and will also be available on www.iciciprulife.com

ICICI Prudential Life Insurance Company Limited.

Communication Address:Vinod Silk Mills Compound,Chakravarthy Ashok Road, Ashok Nagar,Kandivali(E), Mumbai-400 101
Registered Office: ICICI Prulife Towers,1089, Appasaheb Marathe Marg,Prabhadevi,Mumbai-400 025

https://www.icicilombard.com/health-insurance/appmanager/TaxCertificateHome?selectedValues... 2/12/2020