LIC Receipt Generator - Template & Editor

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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: support@licindia.in

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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

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Policyholder Name:

Samantha Lee

Policy Type:

Endowment Plan

Policyholder Email:

samantha.lee@example.com

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

22/01/2026, 08:38:34 AM

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Policy Premium Amount

$12000.00

GST / Charges

$540.00

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Subtotal$12540.00

Discount(5%)$627.00

Tax(15%)$1786.95

Total

$13699.95

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Card Number**** **** **** 4922

Card TypeDebit

Card EntryChip

Date/Time11/20/2019 11:09 AM

Reference #62845289260246240685C

StatusAPPROVED

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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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