Siddappaji

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User Name : SOMU01

Name : SOMASHEAKHARA S

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CERTIFICATE
Name of the member & Address :
SOMASHEAKHARA S KEELARA V&P MANDYA MANDYA Karnataka 571450 9900848036

Membership No Age Nominee Relation

: INS4 : 54

: JAYALAKSMAMMA

: Wife

Details of the Accident Insurance Cover :
M/s.United India insurance Co Ltd.,
Do -3,No-24, 1 st Floor, Clasic Buliding, Richmond Road, Bangalore-560 025. 070300/42/11/05/00000049

1. Name & Address of the Insurer

:

2. Policy no 3. Period of Insurance 4. Death benefit due to any accident

: : :

From : 18 May 2011

To : 17 May 2012

Rs. 1,00,000 /-

LIC Policy Details : file://C:\DOCUME~1\ADMINI~1\LOCALS~1\Temp\VRI57SM0.htm PDF created with pdfFactory Pro trial version www.pdffactory.com 5/24/2011

Page 2 of
1. Policy no 2. Name of Insurer 3. Validity 4. Benefit
Note . : : : : 525133

LIC OF INDIA.,

P & G S Unit, JC Road, Bangalore-2,

From : 18 May 2011

To : 30 Apr 2012

Rs. 5000 /-

1. LIC - Natural Death Benefit is available only for the Members (Dealers) who are aged between 18 years & 55 years only 2. In case more than one user Id on a single name, this benefit of Rs. 5000/*- will be payable to one user Id only. That means maximum benefit payable to a person is Rs. 5000/- only.

This Certificate is issued as per the terms & conditions of Personnael Accident Insurance policy Issued by the Insurance Co.

Date : 18 May 2011 Place : Bangalore

file://C:\DOCUME~1\ADMINI~1\LOCALS~1\Temp\VRI57SM0.htm PDF created with pdfFactory Pro trial version www.pdffactory.com

5/24/2011

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