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LIFE INSURANCE CORPORATION OF INDIA

FORM OF REASSIGNMENT FOR VALUABLE CONSIDERATION

We Manager United bank of India, Allah Pur Branch Allahabad the assignees, in
consideration of the sum of Rs.200000/-repaid to us by Vishal Goel the receipt of which we
hereby acknowledge, do hereby as beneficial owners reassign unto ……………the assured his
heirs, Executors, Administrators and assign the policy of assurance on his life granted to him by
the Life insurance corporation of India, assuring the sum of Rs.20000/- and numbered
312614989 and bearing date the 1st day of Feb 2006 and the sum assured thereby and all other
moneys, benefit and advantages to be received there under.

Dated at Allahabad this 17th day of May 2012.

WITNESS:

Signature………………. (1)…………………….

Full Name………………… Signature of Assigners with Designation

Designation……………. /& official seal or Rubber stamp