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Organization Name: Life Insurance Corporation of India (LIC) Organization Tagline: Yogakshemam Vahamyaham Address Line 1: LIC Central Office, Yogakshema Address Line 2: Jeevan Bima Marg City, State, Zip: Mumbai, MH 400021 Phone: 022-68276827 Website: www.licindia.in Email: [email protected]

-------------------------------------------

Transaction Type: Premium Payment Policy Number: LIC-POL-8842159921 Receipt Number: LIC-REC-20251112-004981 Payment Status: Successful Payment Date & Time: 11/12/2025 10:37:25 AM Payment Mode: Debit Card Card: Visa ending 4922 Authorization Code: LIC-AUTH-6H72F9 Reference Number: LIC20251112R004981 Currency: INR

-------------------------------------------
Policyholder Name:
Samantha Lee
Policy Type:
Endowment Plan
Policyholder Email:
[email protected]
Policy Term:
20 Years
Address:
742 Evergreen Terrace, Apt 9C, Springfield, IL 62704, United States
Premium Mode:
Annual
Due Date:
11/12/2025
Policy Number:
LIC-POL-8842159921
30/06/2026, 09:27:31 PM
-------------------------------------------
1
Policy Premium Amount
$12000.00
1
GST / Charges
$540.00
-------------------------------------------
Subtotal$12540.00
Discount(5%)$627.00
Tax(15%)$1786.95
Total
$13699.95
-------------------------------------------
Card Number**** **** **** 4922
Card TypeDebit
Card EntryChip
Date/Time11/20/2019 11:09 AM
Reference #62845289260246240685C
StatusAPPROVED
-------------------------------------------
-------------------------------------------

Receipt Reference: LIC-2025-1112-009 Customer Care: 022-68276827 Help Center: www.licindia.in/customer-services Thank you for paying your LIC premium. Security Notice: LIC will never ask for your password, PIN, or OTP by email or SMS. Footer: Life Insurance Corporation of India

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