Max Life Insurance Co. Ltd.

Operation Center, 90-A, Udyog Vihar, Sector 18, Gurgaon -- 122015

Customer Help Line -1800 200 5577 (Toll free from any network)
Regd Office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi 110 020, India
Visit us at: www.maxlifeinsurance.com E-mail: service.helpdesk@maxlifeinsurance.com
www.maxlifeinsurance.com

Premium Paid Certificate for the Period 01/05/2015 to 25/01/2016

Policy Number: 250142999 As on Date 25-Jan-2016

Name: Mr. Sudhir Kumar Singh Base Life Insured: Mr. Sudhir Kumar Singh
Address: H NO 8/153 D-2 Your Agent Advisor: Mr. Direct Customer Services Banc
NEW ABADI KAUSHALPUR Assurance
.,AGRA Agent Code 124339
AGRA - 282005 Your Agent Phone No 18002005522
General Office Bancassurance Head Office
Telephone 9045655471,

Dear Mr. Sudhir Kumar Singh,

Thank you for being part of the Max Life Insurance family. This is to acknowledge receipt of your premium for the period 01/05/2015 to 25/01/2016
as per details below.

We also take this opportunity to reiterate that we value your patronage and are committed to providing you the best in class service.

Yours Sincerely,

for Max Life Insurance Co. Ltd.

Authorized Signatory

Plan Sum Insured Premium Current Effective Date

(Rs.) Received # Frequency of Coverage
(Rs.)
Max Life Life Gain Premier 4,96,135.00 49,350.95 Annual 22-Aug-2014
Total 49,350.95

Minimum Guaranteed Death Benefit / Death Benefit of base plan and term rider (if any) : RS 5,33,523.76

Note: || # Subject to realisation of monies. || The total premium amount is inclusive of Service Tax if paid. || This certificate is a consolidation of the individual premium
receipts sent to you. Commencement of risk shall be effective from the date of acceptance of risk. || *** Premium paid towards covering life of specified person would be
eligible for deduction under provisions of Section 80C / 80CCC / 80D of Income Tax 1961, as per applicability and subject to levies under prevailing Tax Laws. || Service tax
and Education cess would be applicable on the premium as per prevailing service tax rate. || We request you to please consult with your tax consultant for more information.

Service Tax Regn. No. AACCM3201EST001

PRM23 V1.9 25092015 25-Jan-2016
E.&O.E.