Max Bupa

Mai radii !gig Wotan Heath inurisr.4.

Tom IheAth first

Plerritall Receipt
Dear Mr. filltin Bansal
330,
mohalla Kalyan Singh Mavina.

Meerut,
Uttar Pradesh - 250401

Ve ack.noviledge the receipt of payment towards the premium aline Moving hearth insurance policy.
P of icy Holders Nor e Mr Nitin Elansal Policy Number 30209660201300

Plan Opted tar Family First Silver 5 lima .,,, 15 /ads Sur Insured (Rs) 4000000

C COI mencern ent Dale. 1000412013 Expiry dale 17,0+4/2014

Net P rem On (Rs.) 45,897.00

Service 1 ax(RE) 5,5013.00

f ducation Cess (Rs.) 110.00

Secondary 8 Higher Education tress (Rs.) 56 00

Gross Premium (Rs.) 51571.00

Starry MO
PStuaricd Of pity r6 lcearance Of pnEr'11.1111 paid
Details of persons Insured
name of person Iris:Lied Age Gender Relalionatipto policy holder rrdiurid<Nl CwirerMs.)
Orq in cam- 011Facitiii First)

Mr. Nrtin Elansa 35 M Applicant

Ms. Withal 23 F Spouse
Mr. Purushottarri Dass 62 M Father
Mr. Darsh Bansal 1 M Son
MS, Maniu Barisal 55 F Mother

Upon issuance of tide receipt all previously issued temporary receipts if any, related to this policy are considered null
and void. For the purpose of deduction under section 60D_ the benefit shall be as per the provisions of the Income Tax Act , 1961
and any ern endm ents made thereafter.
In the event of non-realizerlion of premium, Tax bane Ms cannot be obtained against this premium recerpt.
For your eligibility and deductions please FOCI to PrOVittiOnS Of 'MOM e Tax AO 190.1 atS Killed and contain your lax
consuftirrl_

Service tax Registration ntariber. AAF CM 7916H ST 001

For & On behalf of Max Bupa Hear Insurance Co. Lid.

1411.60./Q511

Planavii-e Matra
C hie( E xeculive Officer

Location: New Delhi

Date : 2511 1 1201 4