Registration

*This form is to be printed, signed and uploaded back to submit the Premier Service
request.

Premier Services Registration

Date of Birth Mobile Number

Name
03/01/1992 85******87
Nimesh Mohanpuria
Passport Number
EmaillD PAN
om********en@gmail.com
BJDPN760sQ

Eligible Policies for Premier Services

Date of Birth Premium ()

Name Policy Number
03/01/1992 6,200.00
Sh.Nimesh Mohanpuriya M85030277
478430671 03/01/1992 29,331.00
Nimesh Mohanpuriya
147415296 03/01/1992 6,442.00
Nimesh Mohanpuria

Service: Registration for LIC's Premier Services"and accept

lhave read the provisions contained in the "Terms of web-site: www.licindia.in under my User-lD and PassWord
them. Iagree that all transactions executed over LIC's
will be binding on me.

Signature