Collecting Branch : EPS1 Servicing Branch : LIC of India, Mumbai B O 915

Jeevan Prakash 2nd Flr

Transaction No : 20097611
Fort Sir P M Road.,Mumbai
Date ( Time ): 07/01/2019 ( 11:10:07 ) Mumbai,400001
bo_eps1@licindia.com
Receipt No : PR2009761100011819
HelpDesk: +91-022-1251

RENEWAL PREMIUM RECEIPT

Received with thanks ` 643.00 through Payment Gateway over the Internet from:

Smt./Ms./Shri : Siddhesh Ravindra Jadhav La

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.
(`) (`) (`)
991153232 102 643.00 1 643.00 0.00 915
Siddhesh 20 QLY 12/18 0.00 0.00 03/19
01955915 18/03/2011 50,000.00 12/18 0.00 643.00

Page Total (`) 643.00 643.00 0.00

0.00 0.00
0.00 643.00
Grand Total (`) 643.00 643.00 0.00
0.00 0.00
0.00 643.00

GST borne by LIC of India ` 14.46

SIX HUNDRED FORTY THREE RUPEES AND ZERO PAISE ONLY

Siddhesh Ravindra Jadhav La

Ravindra Tukaram Jadhav Pr
Saibaba Chs, Chawl No 2,Kokan-
Ngr,Jogeshwari E , Mumbai

400060 Payment Acknowledgement generated through

Online Portal on 07-Jan-19 Time : 11:13:06.
Mobile: 9867899626
Email: Ravituja@gmail.com

This receipt is electronically generated and no signature is required.

Har Pal Aapke Saath!