Date: 09-Oct-2017

Receipt No.: 274923119OCT201701

Life Insurance Premium Receipt

Duration For Which the Premium is Received: to 13-AUG-2018
Personal Details
Policy Number: 274923119 Current residential state: Orissa
Policyholder Name: Mr. Balaji Biswanath Senapati Mobile No. 9853784855
Commuinication Address: S/O SRIPATI SENAPATI Landline no. Please inform us for regular updates
AT/PO AMBALIATHA Life Insured Name: Mr. Balaji Biswanath Senapati
VIA JALESWAR,. PAN Number: BMGPS7781H
BALASORE - 756032
Email ID: Please inform us for regular
updates

Policy Details
Plan Name: Max Life Life Gain Premier - 104N079V01
Policy Term 15 Years Premium Payment Frequency Annual
Date of Commencement 14-AUG-2015 Date of Maturity 14-AUG-2030
Last Premium Due Date Next Due Date 14-AUG-2018
Reinstatement Interest (incl. GST) ` 0.00 Model Premium (incl. GST) ` 21,734.40
Total Premium Received (incl. GST)* ` 21,734.40 Minimum Guaranteed Death Benefit / ` 2,33,817.54
Death Benefit of base plan and term rider
(if any)
Agent's Name Peerless Developers Ltd. Agent's Contact No.
Balasore 812

GST Details
Coverage Type SAC Code GST (INR) GSTIN 21AACCM3201E1ZF
Base 997132 ` 478.26 GST Regd. State Odisha
Rider 997132 ` 0.00
Reinstatement Interest ` 0.00
Total ` 478.26

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

PRM21 V4.8 01072017 2017-10-09.03.35.14.280981