Date: 27/7/2010

Mr. Ramesh S.
No. 15, Elango Street,
Sarah Nagar
Old pallavaram
Chennai
Tamil Nadu
600117
PREMIUM PAID CERTIFICATE FOR THE YEAR 2009-2010

This is to certify that as per our records the following payments have been received by us to effect or
keep "In Force" Life Insurance Policies held by
Mr. Ramesh S.

Life Assured's Name: Ramesh, S.

Policy No.: 07636265 Plan Name:LifeTime Gold

Benefits/Rider Sum Assured Coverage Premium Amount Premium Due UIN

LifeTime Gold 200,000.00 SEC 80 C 23,820.00 0.00 105L077V01
Accdntl Death&Disability Ride 200,000.00 180.00 0.00 105A018V01
Policy Total 24,000.00
Amount in 0.00
Suspense
Total Premium 24,000.00
Premium Due 0.00

Premium Paid to avail Income Tax Benefits Under:

SEC 80 CCC(1) 0.00

SEC 80 C 24,000.00
SEC 80 D 0.00

Total 24,000.00

Please note the mortality charges under the base plan as well as riders (if any) would be recovered every
month as per the Terms and Conditions of the Policy.

The above mortality charges are the actual charges recovered till date. The recovery of such charges would
be subject to change on monthly basis.

This is a computer generated statement and does not require any signature.

ICICI Prudential Life Insurance Company Limited.

Communication Address:Vinod Silk Mills Compound,Chakravarthy Ashok Road, Ashok Nagar,Kandivali(E), Mumbai-400 101
Registered Office:ICICI Prulife Towers,1089, Appasaheb Marathe Marg,Prabhadevi,Mumbai-400 025
Page 1