Collecting Branch : EPS1 Servicing Branch : LIC of India, Hubli Branch I

Post Box No 25
Transaction No : 19408611
L I C Building Lamington Road.,Hubli
Date ( Time ): 01/01/2019 ( 09:48:19 ) Hubli,580020
bo_eps1@licindia.com
Receipt No : PR1940861100011819
HelpDesk: +91-022-1251

RENEWAL PREMIUM RECEIPT

Received with thanks ` 919.00 through Payment Gateway over the Internet from:

Smt./Ms./Shri : Chaitanyakumar Parashuram Kulkarni

towards the following :

Policy No Plan Inst. Premium No Of Inst Total Premium CGST Branch

Name Term Mode Due From Late Fee SGST/UTGST Next Due
Agency Code D.O.C. Sum Assured Due To CD Charges Total Amt Reg. No.
(`) (`) (`)
638245272 165 919.00 1 919.00 0.00 632
Chaitanakumar 15 QLY 01/19 0.00 0.00 04/19
05094632 23/01/2010 75,000.00 01/19 0.00 919.00

Page Total (`) 919.00 919.00 0.00

0.00 0.00
0.00 919.00
Grand Total (`) 919.00 919.00 0.00
0.00 0.00
0.00 919.00

GST borne by LIC of India ` 20.68

NINE HUNDRED NINETEEN RUPEES AND ZERO PAISE ONLY

Chaitanyakumar Parashuram Kulkarni

C/O Y.S.Shisunalli
94, C.I.T.B.Colony Shivananda Nagar
Hubli

580025 Payment Acknowledgement generated through

Online Portal on 01-Jan-19 Time : 09:54:06.
Mobile: 9738184769
Email: chaitu.kulkarni6@gmail.com

This receipt is electronically generated and no signature is required.

Har Pal Aapke Saath!