Name of the Prospect/Policyholder: Ms.

MONIKA TYAGI Proposal No:

Age & Gender: 33 Years, Female Name of the Product: Max Life Super Term Plan

Name of the Life Assured: Ms. MONIKA TYAGI Tag Line: A Non-Linked Non Participating Individual Pure Risk Premium Life Insurance Plan

Age & Gender: 33 Years, Female Unique Identification No: 104N086V04

Non-Smoker GST Rate: 18.00%

Risk Class:
Max Life State: Uttarakhand
Policy Term: 32 Years
Premium Payment Term: 32 Years Policyholder Residential State: Uttarakhand

Amount of Installment Premium: `7,965

Mode of payment of premium: Annual

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy.

Policy Details
Policy Option Level Sum Assured Sum Assured (in Rs.) 50,00,000
Sum Assured on Death (at inception of the policy) (in Rs.) 50,00,000

Rider Details
Accidental Death & Dismemberment (ADD) Rider Term NA Accidental Death & Dismemberment (ADD) Rider Sum Assured (in Rs.) NA
Waiver of Premium (WOP) Plus Rider Term NA

Premium Summary
Base Plan Riders Total Installment Premium
Installment Premium without GST (in Rs.) 6,750 - 6,750
Installment Premium with first year GST (in Rs.) 7,965 - 7,965
Installment Premium with GST 2nd year onwards (in Rs.) 7,965 - 7,965

UIN: 104N086V04 Page 1 of 3

 (Amount in Rupees)

Guaranteed Non Guaranteed

Single/ Annualized
Policy Year
Premium Survival Benefits / Loyalty Min Guaranteed Surrender Value Special Surrender Value
Other Benefits, if any Maturity Benefit Death Benefit
Additions

1 6,750 - - - 50,00,000 - -
2 6,750 - - - 50,00,000 - -
3 6,750 - - - 50,00,000 - -
4 6,750 - - - 50,00,000 - -
5 6,750 - - - 50,00,000 - -
6 6,750 - - - 50,00,000 - -
7 6,750 - - - 50,00,000 - -
8 6,750 - - - 50,00,000 - -
9 6,750 - - - 50,00,000 - -
10 6,750 - - - 50,00,000 - -
11 6,750 - - - 50,00,000 - -
12 6,750 - - - 50,00,000 - -
13 6,750 - - - 50,00,000 - -
14 6,750 - - - 50,00,000 - -
15 6,750 - - - 50,00,000 - -
16 6,750 - - - 50,00,000 - -
17 6,750 - - - 50,00,000 - -
18 6,750 - - - 50,00,000 - -
19 6,750 - - - 50,00,000 - -
20 6,750 - - - 50,00,000 - -
21 6,750 - - - 50,00,000 - -
22 6,750 - - - 50,00,000 - -
23 6,750 - - - 50,00,000 - -
24 6,750 - - - 50,00,000 - -
25 6,750 - - - 50,00,000 - -
26 6,750 - - - 50,00,000 - -
27 6,750 - - - 50,00,000 - -
28 6,750 - - - 50,00,000 - -
29 6,750 - - - 50,00,000 - -
30 6,750 - - - 50,00,000 - -
31 6,750 - - - 50,00,000 - -
32 6,750 - - - 50,00,000 - -

UIN: 104N086V04 Page 2 of 3

Notes: Annualized Premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any, and Goods and Service Tax. Refer Sales literature for explanation of terms used in
this illustration.

I, Ms. Meenakshi Singh (name),have explained the premiums, and benefits under the product I, MONIKA TYAGI (name), having received the information with respect to the above, have
fully to the prospect / policyholder understood the above statement before entering into the contract.

Place:
Date: 5/29/20 Signature / OTP Confirmation Date / Thumb Impression / Date:5/29/20 Signature / OTP Confirmation Date / Thumb Impression /
Electronic Signature of Agent/ Intermediary / Official Electronic Signature of Prospect/ Policyholder
This system generated benefit illustration shall be treated as signed by me.

Page 3 of 3
UIN: 104N086V04 29,33,32,5000000,0,6750.00,F,N,d29