Collecting Branch : EPS1 Servicing Branch : 93C

E-mail : bo_eps1@licindia.com LIC of India, Curchorem Branch Office

Phone : +91-022-1251 Mopkars Chamunda 2nd Floor
Opposite Post Office
Transaction No. : PR0661419300011718 Curchorem Goa.
Curchorem
Date ( Time ): 09/08/2017 ( 10:42:36 ) Goa 403706

RENEWAL PREMIUM RECEIPT

Received with thanks Rs. 3569.00 through Payment Gateway over the Internet from:

Smt./Ms./Shri : Lourenco Vaz

Towards the following

Policy No Plan Inst. Prem(Rs) No Of Inst Total Premium Tax * Branch

Name Term Mode Due Fr Late Fee Total Amt Next Due
Agency Code D.O.C. Sum Assured Due To CD Charges Reg. No.
931301300 179 3,569.00 1 3,569.00 0.00 93C
Lorenco Lv 16 HLY 08/17 0.00 3,569.00 02/18
0025093C 08/08/2011 1,05,000.00 08/17 0.00 30AAACL0582H2ZY
Page Total (Rs) 3,569.00 3,569.00 0.00
0.00 3,569.00
0.00
Grand Total (Rs) 3,569.00 3,569.00 0.00
0.00 3,569.00
0.00

RUPEES THREE THOUSAND FIVE HUNDRED SIXTY-NINE ONLY

Lourenco Vaz
H.No 1253/10, Gandongar,
Shiroda, Goa.
403103

This receipt is electronically generated.

*Tax here indicates Goods and Services Tax(GST) from 1 July 2017 or Service Tax prior to 1 July 2017.

Har Pal Aap Ke Saath

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