STATE INSURANCE DEPARTMENT

(Life-Official Branch)
(This form is to be used for State Life Insurance Official Branch only)

Statement showing deductions an account of premia towards Official Branch Insurance Fund in the establishment Pay of Salary
Bill of general1 for the month of August - 2009

Remarks
Sl No Policy Nos in Serial Name of Policy Holder Designation Month to Amount Loan Rs.
Order which deducted
premium Pr. Rs.
relates
1 280147584 Pramodan K Lab.Techn.Gr II 8/ 2009 150
2 280346893 Beena C H Staff Nurse Gr II 8/ 2009 250
3 280346893 Arrear 5/09 Beena C H Staff Nurse Gr II 8/ 2009 250
4 280450023 Anasooya C Jr.Health Inspector 8/ 2009 150
Gr I
5 280652083 Mathew KJ Health Inspector Gr 8/ 2009 300
II
6 280747664 Pramodan K Lab.Techn.Gr II 8/ 2009 150
7 280789378 Beena C H Staff Nurse Gr II 8/ 2009 100
8 280789378 Arrear 5/09 Beena C H Staff Nurse Gr II 8/ 2009 100
9 280789380 Abdul Kabeer CT LD Clerk 8/ 2009 200
10 280789383 Krishnan K Hospital Attender 8/ 2009 200
Gr. II
11 289450749 Mathew KJ Health Inspector Gr 8/ 2009 30
II
12 28960591 Anasooya C Jr.Health Inspector 8/ 2009 50
Gr I
Total: 1930

Station: Head of Office

Date: 19/08/2009 Designation

Certified that a sum of Rs 1930 /- has been deducted in establishment or salary bill cashed on
19/08/2009
TREASURY OFFICER