*This form is to be printed, signed and uploaded back to submit the Premier Service Registration
request.
Premier Services Registration
Name
Date of Birth
Mobile Number
Suneel Goud Veligatla
31/01/1981
99******58
EmailID
PAN
AEXXXXXX6E
Passport Number
vs********lg@rediffmail.com
Eligible Policies for Premier Services
Name
Veligatla Suneel Goud
Policy Number
Date of Birth
Premium (`)
692747333
31/01/1981
25,666.00
* I have read the provisions contained in the "Terms of Service: Registration for LIC's Premier Services"and accept
them. I agree that all transactions executed over LIC's web-site: www.licindia.in under my User-ID and Password
will be binding on me.
Signature