STATEMENT OF PREMIUMS PAID FOR THE PERIOD 01-APR-2021 to 31-MAR-2022

Client Id: 5012165017 Date: 29-JAN-2023

Name: Mr. Solomon Devaraj Samuel PAN: DVNPS5914N
Address: No 82/1 Rajaji Street Pulipakkam Pulipakkam
Chengalpattu Kanchipuram - 603002
Tamil Nadu, India
Mobile No.: 9789671773
Email Id: soulofs.again@gmail.com

Policy No. Plan Premium Premium Payment Policy

Amount # * (Rs.) Frequency Commencement Date
599878477 Max Life Monthly Income Advantage Plan - 12 Pay 76,687.53 Annual 15-MAR-2019
Total 76,687.53

INTEREST ON LATE PAYMENT (only in case of non-linked plans) : 0.00

Note: || # The Premiums mentioned in this document are subject to realization of the cheques/instruments/monies. || *The total premium amount is inclusive of
IGST/CGST/SGST as may be applicable. || This statement summarizes premiums paid by you in the specified period and is being used in addition to the receipts
which we have already issued and sent to you on your payment of premiums || Above premiums may be eligible for tax benefit under Section 80C / 80CCC
/ 80D of Income Tax Act 1961.Tax benefits as mentioned in the policy are subject to prevailing tax laws, which are subject to change. You are advised to seek
the opinion of your tax advisor in relation to applicable tax benefits and liabilities.
I/We hereby declare that though our turnover is more than the turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms
of the said sub-rule.
To serve you better, we request you to please update your email id and latest contact number by clicking https://bit.ly/2O4S2VT or you can email the
change request at service.helpdesk@maxlifeinsurance.com

CON23 V2.0 19012023