Mr.

Gautam Mehra
Flat No 502, Sai Prasad Chs,
Plot No 2, Sector 20,
Kharghar, Navi Mumbai
Dist – Raigad. Pin: 410210

Premium Paid Certificate for the year 2017 – 2018.

This is to certify that as per our records the following payments have been received by us to effect or keep “In Force” Life
Insurance Policies held by : - Mr. Gautam Mehra

Life Assured‘s Name: - Mr. Gautam Mehra

Policy No: 005891624. Plan Name: Life Time

Benefit / Rider Sum Assured Coverage Premium
Amount

ICICI Pru Life Time 20,00,000 Sec 80 C 90,000

Policy Total 90,000

Premium Paid to Avail Income tax Benefits Under: -

Sec 80 c 90,000
_______________

Total 90,000

_______________

Please note that the mortality charges under the base plan as well as riders (if any) would be recovered every month
as per the terms and conditions of the policy.

The above mortality charges are the actual charges recovered till date. The recovery of such charges would be
subject to the change on monthly basis.

This is a computer generated statement and does not require any signature.

ICICI Prudential Insurance Company Limited.