Name: abc Sum Assured: 400000.

00
DateOf Birth: 31/03/2013 Policy Term: 10
Age in(yrs): 9 PPT: 10

Gender: Male Mode: YEARLY

Benefit Illustration for SHRIRAM LIFE ASSURED INCOME PLAN V04

128N053V04
(This Benefit Illustration forms part of the Policy Document)

Guaranteed Non Guaranteed

 Policy  Total Annualized  Survival Benefits /   Other Benefits   Maturity Benefit   Death Benefit   Min Guaranteed   Special Surrender Value 
  Year  Premium paid till Loyalty Additions  if any  Surrender Value  
date  
1 40000 0.00 0 0 40000 0 0

2 40000 0.00 0 0 484000 24000 14520

3 40000 0.00 0 0 484000 42000 31944

4 40000 0.00 0 0 484000 80000 57499

5 40000 0.00 0 0 484000 116000 92686

6 40000 0.00 0 0 484000 158400 138230

7 40000 0.00 0 0 484000 210000 195826

8 40000 0.00 0 0 484000 268800 266006

9 40000 0.00 0 0 484000 334800 350658

10 40000 0.00 0 0 484000 408000 450120

11 0 0.00 0 66960 0 0 0

12 0 0.00 0 66960 0 0 0

13 0 0.00 0 66960 0 0 0

14 0 0.00 0 66960 0 0 0

15 0 0.00 0 66960 0 0 0

16 0 0.00 0 66960 0 0 0

17 0 0.00 0 66960 0 0 0

18 0 0.00 0 66960 0 0 0

19 0 0.00 0 66960 0 0 0

20 0 0.00 0 66960 0 0 0

Disclosures:
(1) This is only an illustration and does not in any way create any rights and/or obligations.
(2) This illustration is applicable to a healthy individual acceptance of the proposal is subject to underwriting.Premiums relating to riders and non-
standard risks are excluded from the above.
(3) The above amounts assume that all premiums have been paid on due date.
(4) The surrender value payable will be the maximum of GSV and SSV.
(5) Please contact nearest branch office for latest surrender values payable on your policy.

Policy Details
Death Benefit Pay-Out Option Lumpsum Sum Assured Rs. 400000.00
Maturity Benefit Pay-Out Option Payout Sum Assured on Death (at inception of the policy) Rs. 40000
Premium Summary
Base Plan Riders Total Instalment Premium
Instalment Premium without GST 40000 0 40000
Instalment Premium with First Year GST 41800 41800
Instalment Premium with GST 2nd Year Onwards 40900 40900
Notes:
1) Annualized premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders,
if any Goods & Service Tax.

IRDAI Regn No:128

I, .........................................., have explained the premiums, and benefits I, ........................................
under the product fully to the prospect / Policyholder. having received the information with respect to the above, have
understood the above statement before entering into the contract

Date: Signature of Agent / Intermediary / Date : Signature of the Prospect/

Official /Specified Person Policy holder's signature
Place: