Bajaj Allianz Life Insurance Co. Ltd.

Date: 03/02/2011

TO,
MR GHANSHYAM BARAL
R/O VASANY VIHAR
SIVALIK FACTORY KE SAMNE~
GAJRAULA
JYOTIBA PHULE NAGAR
UTTAR PRADESH
244235
Certificate For Premium Paid
(01-Apr-2009 to 31-Mar-2010)

Assignee:

This is to certify that the premium under the following policies taken by the policy holder MR GHANSHYAM BARAL has been received by Bajaj
Allianz Life Insurance Company Limited during the financial year 2009-2010.

Policy No Product Premium Premium Premium Sum Premium Life Health Care Service Tax
Due Date Adjustment Type Assured Amount Insurance Premium(2) Including
Date Received Premium(1) Edu.cess
0158310466 SUPER First
11/03/10 11/03/10 21000 2920 2920 0 30.07
SAVER Premium
Total : 2920 2920 0 30

_____________________
Authorised Signatory
For Bajaj Allianz Life Insurance Company Limited.

Note:
Total Premium amount received as mentioned above is eligible for income Tax Rebate wherever applicable as per the provisions of income Tax
Act, 1961. For actual eligiibilty please refer to provisions of IT Act 1961 as modified and consult your tax consultant.

Note: This is a computer-generated letter and does not required a signature.

Regd. & Head Office: GE Plaza, Airport Road, Yerwada, Pune 411 006. Tel (+91 20) 66026777. Fax (+91 20) 66026789.

Customer Helpline : 020 30587888 Toll Free No : 1800 233 7272