SUD LIFE DHAN SURAKSHA PREMIUM 3 PLAN

UIN: 142L025V01
POLICY DOCUMENT
Corporate Agent Name: Union Bank of India
CIE Name: Mr.Kishore N. Makhijani
Specified Person Name: Nikhil Soni
Specified Person Code: 80001624
Specified Person Contact No.: 9685591234/
Specified Person Email ID: nikhillsoni@yahoo.co.in
In this policy, the investment risk in investment portfolio is borne by the policyholder.

The Proposer and/or the Life Assured named in the Schedule of this Policy having submitted a proposal together
with a Personal Statement and Declaration and the first installment of premium specified in the Schedule to the
STAR UNION DAI-ICHI LIFE INSURANCE COMPANY LIMITED [the “Company” which expression shall include
its assigns and successors] for grant of the benefits specified in the Schedule, it is agreed by the Company and
the Proposer and/or the Life Assured (the “Parties”) that the proposal, the Personal Statement and the Declaration
together with any report or other document leading to the issue of this Policy shall form the basis of this contract
of assurance do hereby further agree that in consideration of the receipt of future premiums as stated in the
Schedule, the Company will pay such benefits [without interest] as herein stated, to the Beneficiary, on submission
of proof to the complete satisfaction of the Company of the benefits under the Policy having become payable in
accordance with the terms and conditions hereof and of the Beneficiary’s entitlement to them. It is further agreed
by and between the Parties that any endorsement executed either on the Policy itself or through a separate
instrument by the Company and any special provisions subject to which this Policy has been issued and any
Annexures and Addendums hereto shall together form part of the Policy. It is also agreed that this Policy shall be
governed by the laws of India in force from time to time and all premiums and benefits shall be payable in Indian
Rupees only. The benefits attached to and the Premiums [including the Rider premiums if applicable] payable
under this Policy will be subject to taxes and other statutory levies as may be applicable from time to time, and
such taxes, levies etc will be recovered, directly and completely from the Policyholder.
SCHEDULE I
Policy Number: 00551175
Name of the Proposer: Mr Aashutosh Kumar Upadhyay
Name and Address of the Mr Aashutosh Kumar Upadhyay
Life Assured: Vill Post Sonauri
Tehsil Teonthar
Rewa
Madhya Pradesh-486226

Date of Birth of Life Age of the Age

05/11/1987 24 years Y
Assured Life Assured Admitted
Relationship of
Name of the Nominee: Mr Arvind Kumar Upadhyay Nominee to the Brother
Life Assured
Date of Birth of the
11/08/1982 Age: 30 years
Nominee:
Name of the Appointee: N.A
Relationship to the Age: N.A
N.A
Nominee
Date of proposal: 31/07/2012 Application Number: 31723010
Client ID 51045419
Date of Commencement of Date of Commencement
10/10/2012 10/10/2012
Policy: of Risk:
Sum Assured Multiplicator Basic Premium:
N.A. 100,000.00
Factor (SAMF):
Due Date of Last
Premium Periodicity Single Premium NA
Premium:

Expiry of the
Premium
Nature of the Benefit Sum Assured Term Term / Maturity
Payment Term
Date
Dhan Suraksha Prm 3 - S 125,000.00 10 N.A 10/10/2022

Investment Options:
Allocation of Regular/Limited/Single Premiums: Effective Date:10/10/2012
The Regular/Limited/Single Premiums received, after deduction of applicable Premium Allocation Charges and
Mortality Charges (and Extra Mortality Charges, if any), are utilised to purchase Units in the relevant Funds as per
the percentages indicated below.

Allocation of Top Up Premium: Effective Date: NA

The Top-up Premiums received, after deduction of applicable Charges, is utilised to purchase Units in the relevant
Funds as per the percentages indicated below. In the event that no Allocation Percentages are indicated by the
Policy holder at the time the payment of Top-up premium is made, the Allocation Percentages applicable to the
Regular/Limited/Single Premiums at that time will be used by the Company for this purpose.

Fund Allocation for Top Up

Fund Name Fund Allocation for Premium in %
Premium in %
UL Ind Life Apex Growth - ULIF 010
60.00 N.A.
20/01/10 SUD-LA-GR1 142
UL Ind Life Apex Balance - ULIF 011
40.00 N.A.
20/01/10 SUD-LA-BL1 142
(Please refer to Section 6 of Schedule III of this Policy for the description of the Funds.The Company reserves the
right to add to, modify or close any of the above mentioned funds subject to the prior approval of the IRDA).

Benefits are payable to: The Policy holder , the assignee where a valid assignment / transfer has been recorded
(in accordance with Section 38 of the Insurance Act 1938), or in the event of death of the Life Assured, the
nominee where a valid nomination has been registered (in accordance with section 39 of the Insurance Act 1938),
with the Company, or in the event of death of the Life Assured where there is no valid nomination, the Executors,
Administrators or other legal representatives of the Policyholder, or to such person as directed by a court of
competent jurisdiction in India (the person/s to whom the benefits are payable under this Policy are herein referred
to as the “Beneficiary”). The benefits payable are limited at all times to the monies payable under this Policy.

The Company will pay the appropriate benefits (without interest) as herein stated, to the Beneficiary on proof to the
complete satisfaction of the Company, in its sole discretion, of the benefits under thePolicy having become
payable and of the right of the Beneficiary to the benefits.
Special Provisions (if any) : N.A.

Signed for and on behalf of Star Union Dai-ichi Life Insurance Company Limited
Mumbai, 10/10/2012

Authorised Signatory

This document is digitaly signed

The Stamp Duty of Rs 25.00 (Rupees Twenty Five Only) paid by pay order, vide receipt no 14668 dated
27/07/2012.
Version: 1.0
 First Premium Receipt

We acknowledge receipt of Rs. 100,000.00/- as deposit towards your proposal for life assurance. The money deposited by
you has been adjusted towards first premium / single premium under this policy, as per the details shown below.

Life Assured : Mr Aashutosh Kumar Upadhyay Date : September 29, 2012

Policy Holder : Mr Aashutosh Kumar Upadhyay Receipt No. : 2331532

Policy No. : 00551175

Application No. : 31723010

Address : Vill Post Sonauri

Tehsil Teonthar, Rewa
Madhya Pradesh - 486226

Date of Commencement Frequency of Payment Next Premium Due Date

10/10/2012 Single NA

Policy No Amount Premium Amount Backdating O/S Balance in

Received Adjusted Interest Deposit
00551175 Rs. 100,000.00 Rs. 100,000.00 NA Rs. 0.00

Yours Sincerely,

For Star Union Dai-ichi Life Insurance Co. Ltd.

Authorised Signatory

This document is digitaly signed

Consolidate Revenue Stamp Duty Paid : Notification No Mudrank - 71745-12/08/11

Note:

A. Amount received by cheque is subject to realisation of cheque.

B. Eligible for Income Tax rebates as per rules.

C. Service Tax applicable as per prevailing service tax law.

Category : Life Insurance. Service tax registration no. AALCS3949QST001

_____________________________________________________________________________________________________
_________
Regd Office: Star House 3rd Floor, (West wing), C-5, ‘G’ Block, Bandra-Kurla Complex, Bandra (East), Mumbai – 400 051.
 FUND VALUE STATEMENT

SUMMARY OF INVESTMENTS

Life Assured : Mr Aashutosh Kumar Upadhyay Date : 10/10/2012

Policy Holder : Mr Aashutosh Kumar Upadhyay Policy No. : 00551175

Address : Vill Post Sonauri

Tehsil Teonthar, Rewa
Madhya Pradesh - 486226

Transaction Summary
Charges Deducted
Premium Amount : Rs. 100,000.00 Mortality Charges : Rs. 11.69

Premium Allocation Charges : Rs. 5,000.00 Policy Administration Charges : Rs. 25.00

Net premium Invested : Rs. 95,000.00

TYPE OF FUNDS No.of Units NAV Amount

UL Ind Life Apex Growth - ULIF 010
4980.67 Rs. 11.36 Rs. 56,604.79
20/01/10 SUD-LA-GR1 142
UL Ind Life Apex Balance - ULIF 011
3223.69 Rs. 11.71 Rs. 37,736.52
20/01/10 SUD-LA-BL1 142
Net Amount Rs. 94,341.31

Income tax Benefits:

Dhan Suraksha Premium 3, SUBJECT TO CONDITIONS MENTIONED U/S 80C SERVICE TAX AND EDUCATION CESS EXTRA,
AS APPLICABLE SERVICE TAX DETAILS: CATEGORY OF SERVICE: LIFE INSURANCE SERVICE REGISTRATION NO:
MIV/ST/IAS-LIFE/1;PAN BASED STC NO: AAAC17351PST001.

UIN-Unique Identification Number specified by IRDA Dhan Suraksha Premium 3 - 142L025V01

The risk for the company under this starts with effect from the date of the issuance of this policy or the data of encashment of first
premium deposit, whichever is later.

In any case, the policy shall stand cancelled in case of non-encasement of the first premium deposit.
This is as authenticated Receipt/Intimation/Statement In case of any discrepancies, Kindly notify us within 14 working days.