Collecting Center : A001 Branch Code : 862

LIC of India, Surat Branch Office III

Transaction No. : 54879112 Jeevan Prakash 4th Flr
Surat.
Date ( Time ): 29/09/2017 ( 19:10:03 ) Surat, 395003
email: bo_862@licindia.com
HelpDesk: +91-022-1251

RENEWAL PREMIUM RECEIPT

Received with thanks Rs. 5,230.00 from policyholder Shri/Smt.Dev Chetanbhai Kotadiya/La
towards the following policy/ies

Policy No Plan Inst. Prem(Rs) No Of Inst Total Premium Tax * Branch

Name Term Mode Due Fr Late Fee Total Amt Next Due
Agency Code D.O.C. Sum Assured Due To CD Chgs Reg. No.
865355152 178 5,230.00 1 5,230.00 0.00 862
Kotadiya D C Dck 98 YLY 09/17 0.00 5,230.00 09/18
00787862 16/09/2010 1,00,000.00 09/17 0.00 24AAACL0582H2ZR
Page Total (Rs) 5,230.00 5,230.00 0.00
0.00 5,230.00
0.00
Grand Total (Rs) 5,230.00 5,230.00 0.00
0.00 5,230.00
0.00

RUPEES FIVE THOUSAND TWO HUNDRED THIRTY ONLY

Paid by Cash/Card :0.00
Paid by Cheque :5,230.00
Cheque No :66248
Cheque Date :28/09/2017

Dev Chetanbhai Kotadiya/La Consolidated Stamp Duty Paid

Chetan Sureshbhai Kotadiya AMuSh2016/2967/CR747/M1 w.e.f. 30/11/2016
142,Surbhi Vihar Soc.,
Bombay Market Road,Surat.
395010. For Life Insurance Corporation of India,
Mobile: Ambabhai Lavjibhai Lathiya(00787862)
Email:

*Tax here indicates Goods and Services Tax(GST) from 1 July 2017 or Service Tax prior to 1 July 2017.
This receipt is subject to realisation of cheque amount.

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