02-01-2018

Premium Certificate
Financial Year 2017-2018
To whomsoever it may concern

Dharmendra Kumar Sharma

A 460 Krishna Nagar
Bagu Byepass Vijay Nagar
Nr Rose Belly Public School
Ghaziabad Uttar Pradesh
Uttar Pradesh
Pin: 201009
Phone1:
Phone2: 9015150192

Client ID: 57086831

This is to confirm that we have received premium(s) from the above named Policy holder under the Policy No (s) as per
details given below

Policy No: 02913518

Cess, as
Plan Component Premium(A) S.Tax/GST(B)*
applicable(C)*

Kotak Assured Income Plan (UIN-107N069V03) 30600 612 20

Policy No: 03072609

Cess, as
Plan Component Premium(A) S.Tax/GST(B)*
applicable(C)*

Kotak Premier Money Back Plan (UIN-107N083V01) 10185 229 -

Premiums are eligible for tax deduction under Section 80C/80CCC of Income Tax Act, 1961. Tax laws are subject to
change from time to time.Please consult your tax advisor for implications.

Additional Premium due for Financial Year 2017-2018

Policy Plan Component Premium Due Premium Due Date Frequency

Kotak Premier Money Back Plan

03072609 10414 19-Mar-2018 Half Yearly
(UIN-107N083V01)

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Notes:

1 Goods and Services Tax and Cess, as applicable is levied at the tax rates in force which is subject to changes from
time to time.
2 Goods and Services Tax category: Life Insurance Services and Management of Investment under ULIP Services.
3 Goods and Services tax is applicable from 1st July' 2017.
4 This is a computer generated advice and does not require any signature.
5 In order to abide by the Foreign Account Tax Compliance Act (FATCA), kindly submit Insurance FATCA
Declaration, separately, if the answer to any of these questions is a `yes': (i) Are you a citizen of any other country
apart from India (dual or multiple citizenship); (ii) Are you a resident (for tax purposes) of any other country other
than India; (iii) Do you hold a green card of USA or any similar card for any other country?
It is mandatory for you to report any future changes in your tax status to Kotak Life Insurance within 30 days of such
change. Until we receive a written intimation about any such change, we shall presume that there is no change in
your tax residency status and consider your earlier submitted declarations, if any, as valid. For any queries about
your tax residency, please contact your tax advisor.

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Premium Payment History

Policy No Receipt No Paid Date Paid Amount Frequency

02913518 AT861267 10-Nov-2017 15644 HALF YEARLY

02913518 AR704673 10-May-2017 15588 HALF YEARLY

03072609 AT668042 20-Sep-2017 10414 HALF YEARLY