Life Insurance Corporation of India

PCMC,Network Operating Center

1st Floor,Jeevan Seva Annexe
S.V. Road,SantaCruz(W)
Mumbai - 400 054

PREMIUM PAID STATEMENT FOR THE YEAR 2021-2022

DATE OF ISSUE :12/01/2022

The following premium has been received for life insurance policies

Premium/ Service
Number of Tax / GST
Instalments Additional Received
Policy Number Date Of Due From Amount Coll. Br.
and Premium Date
Policy Holder's Name Commence. Due To Received * Serv. Br.
Payment Amount
mode (`) (`)
401755715 14/04/2021 1 B041
14/05/2018 1,407.00 31.64 16/04/2021
Bubai Purkait 14/04/2021 Mly 41F

401755715 14/05/2021 1 B041

14/05/2018 1,407.00 31.64 15/05/2021
Bubai Purkait 14/05/2021 Mly 41F

401755715 14/06/2021 1 B041

14/05/2018 1,407.00 31.64 15/06/2021
Bubai Purkait 14/06/2021 Mly 41F

401755715 14/07/2021 1 B041

14/05/2018 1,407.00 31.64 15/07/2021
Bubai Purkait 14/07/2021 Mly 41F

401755715 14/08/2021 1 B041

14/05/2018 1,407.00 31.64 16/08/2021
Bubai Purkait 14/08/2021 Mly 41F

401755715 14/09/2021 1 B041

14/05/2018 1,407.00 31.64 15/09/2021
Bubai Purkait 14/09/2021 Mly 41F

401755715 14/10/2021 1 B041

14/05/2018 1,407.00 31.64 15/10/2021
Bubai Purkait 14/10/2021 Mly 41F

401755715 14/11/2021 1 B041

14/05/2018 1,407.00 31.64 15/11/2021
Bubai Purkait 14/11/2021 Mly 41F

401755715 14/12/2021 1 B041

14/05/2018 1,407.00 31.64 16/12/2021
Bubai Purkait 14/12/2021 Mly 41F
All the above payments are subject to cheque realisation, wherever applicable.

Total amount received towards premium for the policies listed above is ` 12,663.00 for the financial year
2021-2022.

Total amount received towards Service Tax / GST for the policies listed above is ` 284.76 for the financial year
2021-2022.

* Please note GST is applicable from 1st July, 2017.

This document is electronically generated. In case of any queries, please send SMS as follows -- type "LICHELP
<policy no>" and send it to 9222492224. Our Customerzone Official will get in touch with you shortly.