RENEWAL PREMIUM RECEIPT

Name of Policy Holder

Name of Life Assured

RENEWAL PREMIUM RECEIPT

TOTAL

From 26/02/2015 to 26/08/2015

Mr. RAJENDRA VARMA MANDAPUDI

Mr. RAJENDRA VARMA MANDAPUDI

26/02/2015 93485908 17510921 105N114V02 9000.00 135.00 4.00 0.00

0.009139.00

Pay Premiums AutomaticallySet up Standing Instrunctions (SI) usingyour credit card while paying your premiumonline.

Save Time

Avoid Late Charges

Its Free, No DocumentationRequired

# UIN-Unique Identification NO. Specified by IRDA.*For Ulip Policies,Service Tax and Education Cess are deducted by way of cancellation of Units.**The amount indicated as balance in deposit(if any) will be adjusted towards future premium. No interest will be payable on Balance in Deposit

CONSOLIDATED REVENUE STAMP DUTY PAID : NOTIFICATION NO - MUDRANK 0715/0001994074201415/CR-322/M1-13/10/2014

Receipt Number

Policy Number

Product Name / Riders PremiumAmount

Rs.

Reinstatement Amount

Rs.

Balance in Deposit**

Rs.

Receipt Date

Visit www.iciciprulife.com/si to set upStanding Instructions now!

Service Tax*Rs.

Education Cess*Rs.

GuaranteedSavingsInsurancePlan

UIN#