Name: xxxxx Sum Assured: 1000000.

00
DateOf Birth: 17/09/1977 Policy Term: 10
Age in(yrs): 46 PPT: 10

Gender: Male Mode: YEARLY

Benefit Illustration for SHRIRAM LIFE ASSURED INCOME PLAN V04

128N053V04
(This Benefit Illustration forms part of the Policy Document)

Guaranteed Non Guaranteed

Policy Total Annualized Survival Benefits / Other Benefits Maturity Benefit Death Benefit Min Guaranteed Special Surrender Value
Year Premium paid till Loyalty Additions if any Surrender Value
date
1 100000 0.00 0 0 1150000 0 0

2 100000 0.00 0 0 1150000 60000 34500

3 100000 0.00 0 0 1150000 105000 75900

4 100000 0.00 0 0 1150000 200000 136620

5 100000 0.00 0 0 1150000 290000 220225

6 100000 0.00 0 0 1150000 396000 328440

7 100000 0.00 0 0 1150000 525000 465290

8 100000 0.00 0 0 1150000 672000 632040

9 100000 0.00 0 0 1150000 837000 833175

10 100000 0.00 0 0 1150000 1020000 1069500

11 0 0.00 0 147000 0 0 0

12 0 0.00 0 147000 0 0 0

13 0 0.00 0 147000 0 0 0

14 0 0.00 0 147000 0 0 0

15 0 0.00 0 147000 0 0 0

16 0 0.00 0 147000 0 0 0

17 0 0.00 0 147000 0 0 0

18 0 0.00 0 147000 0 0 0

19 0 0.00 0 147000 0 0 0

20 0 0.00 0 147000 0 0 0

Disclosures:
(1) This is only an illustration and does not in any way create any rights and/or obligations.
(2) This illustration is applicable to a healthy individual acceptance of the proposal is subject to underwriting.Premiums relating to riders and non-
standard risks are excluded from the above.
(3) The above amounts assume that all premiums have been paid on due date.
(4) The surrender value payable will be the maximum of GSV and SSV.
(5) Please contact nearest branch office for latest surrender values payable on your policy.

Policy Details
Death Benefit Pay-Out Option Lumpsum Sum Assured Rs. 1000000.00
Maturity Benefit Pay-Out Option Payout Sum Assured on Death (at inception of the policy) Rs. 1150000
Premium Summary
Base Plan Riders Total Instalment Premium
Instalment Premium without GST 100000 0 100000
Instalment Premium with First Year GST 104500 104500
Instalment Premium with GST 2nd Year Onwards 102250 102250
Notes:
1) Annualized premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders,
if any Goods & Service Tax.

IRDAI Regn No:128

I, .........................................., have explained the premiums, and benefits I, ........................................
under the product fully to the prospect / Policyholder. having received the information with respect to the above, have
understood the above statement before entering into the contract

Date: Signature of Agent / Intermediary / Date : Signature of the Prospect/

Official /Specified Person Policy holder's signature
Place: