Date: 13-Dec-2017

Receipt No.: 139684310 DEC201701

Life Insurance Premium Receipt

Duration For Which the Premium is Received: 12-DEC-2017 to 11-JAN-2018
Personal Details
Policy Number: 139684310 Current residential state: Bihar
Policyholder Name: Mr. Manoj Kumar Mobile No. 8986490886
Commuinication Address: FLAT NO. 101 RAM RISHI Landline no. Please inform us for regular updates
APARTMENT PROFESSOR Life Insured Name: MR. MANOJ KUMAR
COLONY PAN Number: BQJPK5050N
NORTH SHASTRI NAGAR
Patna - 800023
Email ID: CSE.MANU@GMAIL.COM

Policy Details
Plan Name: Max Life Online Term Plan PlusMax Life Waiver Of Premium Plus Rider CO - 104N092V02
Policy Term 40 Years Premium Payment Frequency Monthly
Date of Commencement 12-DEC-2017 Date of Maturity 12-DEC-2057
Last Premium Due Date 12-DEC-2017 Next Due Date 12-JAN-2018
Reinstatement Interest (incl. GST) ` 0.00 Model Premium (incl. GST) ` 1,344.60
Total Premium Received (incl. GST)* ` 1,344.60 Total Sum Assured of base plan and term ` 1,00,00,000.00
rider (if any)
Agent's Name Coverfox Insurance Brokin Agent's Contact No.
18002005522
Head Office

GST Details
Coverage Type SAC Code GST (INR) GSTIN 27AACCM3201E1Z3
Base 997132 ` 194.83 GST Regd. State Maharashtra
Rider 997132 ` 10.28 Affix
Reinstatement Interest ` 0.00 Re1
revenue
Total ` 205.11
stamp

Important Note:
*For payment mode other than in cash, this receipt is conditional upon the credit in our account. Payment of premium amount does not constitute commencement of risk. The risk
commencement starts after acceptance of risk by us. *Amount received would be adjusted against the due premium as per terms and conditions of the policy. *Premium paid would be
eligible for deduction as per the provision of Income Tax Act, 1961. Kindly consult your tax advisor for more information. Tax benefits are liable to change due to changes in legislation
or government notification. *Applicable Taxes, Cesses and Levies, as per prevailing laws, shall be borne by you. *For GST purposes,this premium receipt is Tax Invoice.Assessable
Value in GST for Endowment First Year is 25%, Renewal Year is 12.5%; Single Premium Annuity is 10%; Term and Health is 100%. In case of unit linked product GST is applicable
on charges.

Authorised signatory

PRM20