*This form is to be printed, signed and uploaded back to submit the Premier Service Registration

request.

Premier Services Registration

Name Date of Birth Mobile Number

Mangesh Wamanrao Shire 05/04/1977 93******81

EmailID PAN Passport Number

ma********re@rediffmail.com BDXXXXXX3G

Eligible Policies for Premier Services

Name Policy Number Date of Birth Premium (`)

Mangesh Wamanrao Shire 976632986 05/04/1977 3,270.00

Mangesh Wamanrao Shire 976633220 05/04/1977 5,553.00

* I have read the provisions contained in the "Terms of Service: Registration for LIC's Premier Services"and accept
them. I agree that all transactions executed over LIC's web-site: www.licindia.in under my User-ID and Password
will be binding on me.

Signature