Date: 12-Dec-2022

Receipt No.: 17RB634247

Health Insurance Premium Receipt

Duration For Which the Premium is Received: 12-DEC-2022 to 11-DEC-2023
Personal Details
Policy Number: 179184330 Current residential state: Rohtak
Policyholder Name: Mrs. Ashraf Siddique Mobile No. 8860653606
Commuinication Address: House no-20, Ward No-5 Landline no. Please inform us for regular updates
Near Ganpati Tent House Health Insured Name: MR. ASHRAF
Camp Area, PAN Number: CHAPA7628B
GANDHI NAGAR Camp
Rohtak - 124001
Email ID: tech.shanu786@GMAIL.COM
Policy Details
Plan Name: Max Life Online Term Plan PlusMax Life Waiver Of Premium Plus Rider CO - 104N092V02
Health Policy Term 1Year Premium Payment Frequency Yearly
Date of Commencement 12-DEC-2022 Date of Maturity Till 11-Jan-2027
Last Premium Due Date 12-DEC-2022 Next Due Date 12-Jan-2024
Reinstatement Interest (incl. GST) ` 0.00 Model Premium (incl. GST) 103,744.60
Total Premium Received (incl. GST)* 103,744.60 Total Sum Assured of base plan and term 5,00,00,0.00
rider (if any)
Agent's Name Coverfox Insurance Brokin Agent's Contact No.
18002005522
Head Office

GST Details
Coverage Type SAC Code GST (INR) GSTIN 27AACCM3201E1Z3
Base 997132 ` 194.83 GST Regd. State Delhi
Rider 997132 ` 10.28 Affix
Reinstatement Interest ` 0.00 Re1
revenue
Total ` 205.11
stamp

Important Note:
*For payment mode other than in cash, this receipt is conditional upon the credit in our account. Payment of premium amount does not constitute commencement of risk. The risk
commencement starts after acceptance of risk by us. *Amount received would be adjusted against the due premium as per terms and conditions of the policy. *Premium paid would be
eligible for deduction as per the provision of Income Tax Act, 1961. Kindly consult your tax advisor for more information. Tax benefits are liable to change due to changes in legislation
or government notification. *Applicable Taxes, Cesses and Levies, as per prevailing laws, shall be borne by you. *For GST purposes,this premium receipt is Tax Invoice.Assessable
Value in GST for Endowment First Year is 25%, Renewal Year is 12.5%; Single Premium Annuity is 10%; Term and Health is 100%. In case of unit linked product GST is applicable
on charges.

Authorised signatory

PRM20