Provisional Premium Payment Certificate

Financial Year: 2019-2020

Date: 19-Jul-2019

MS. RITA DEVI

WARD 10 GRAM BELWATIYA POST,
SUKUL PAKAR SUGAULI,
MOTIHARI, 845456,
5.
Mobile Number: 9113394873

Application and Premium Details

Application Premium Payment Premium Due Premium Paid

Product/ Rider Name Deductions*
Number Frequency (In `) (In `)

OS11589090 ICICI Pru Life Time Classic Yearly 150000 150000

Total Premium Paid: 150000

Total Premium Due: 150000

Premium Paid in Advance: 0

This is only a provisional certificate and does not communicate acceptance or commencement of risk under the proposal
submitted by you. This document may be used as a proof for claiming deductions while filing your tax returns, subject to
provisions of relevant tax sections and acceptance of risk, i.e. on policy issuance by the Company.

Policy issuance will be subject to:

1) Receipt and clearance of the first premium deposit by the Company
2) Receipt and verification of KYC document and any other documents

Deductions can be claimed subject to conditions prescribed in the relevant sections of Income Tax Act, 1961. Premium paid in advance will be applied to the policy on
premium due date. Premium due amount is considered from last unpaid premium. If the payment has been made other than in cash, this premium paid certificate is
conditional upon credit in company s account post clearance of the instrument/facility including electronic mode. For any confirmation / impact analysis customer is
advised to refer the matter to his Tax consultant.

Tax laws are subject to amendments from time to time. Registered Address: 1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai 400025. Reg No.: 105. CIN
No.:U66010MH2000PLC127837. You can email us at lifeline@iciciprulife.com or visit us at www.iciciprulife.com. Comp/doc/Sept/2016/490.
UIN No. 105L155V03.