Life Insurance Corporation of India Name of Treasury: Sub Treasury, Kondotty

Kerala Sate Government Servant's Policies Designation of Drawing Oficer: Medical Officer

Statement showing deductions on account of Premia ( This statement in Duplicate should be completed after varifying the Register of
towards Life Insurance Corporation of India policies from Insurance Premiums, vide-Annexure C, Appendix II of the Kerala Financial Code
Pay/Salary Bill for August 2009 Vol II maintained in the Office. One copy to be send along with the Pay Bill and
the other to be retained in the Office along with the copy of the Pay Bill )
Name and Address of Institution :- P.H.C KUZHIMANNA

Code No :

general1

Premium (Before Remarks

Month to which Amount (Such as
Sl.No PEN Name of Policy Holder Policy No. Rounding off )
the recovery deducted Rs. transfers
Rs.
etc.)
1 376427 Anasooya C 791911012 August/2009 310.00
608
Anasooya C 791938992 August/2009 298.00
2 340332 Beena C H 791912004 August/2009 351.00
Beena C H 791946021 August/2009 279.00
Beena C H 791912004 August/2009 351.00
Arrear 5/09 1820
Beena C H 791946021 August/2009 279.00
Arrear 5/09
Beena C H 795360194 August/2009 560.00
3 373609 Mathew KJ 791944557 August/2009 727.00
Mathew KJ 790691520 August/2009 192.00 1085
Mathew KJ 790690212 August/2009 166.00
4 300528 Pramodan K 791294698 August/2009 120.00
345
Pramodan K 792688062 August/2009 225.00
Total 3,858

Three Thousand Eight Hundred Fifty Eight

Place:

Date : 19/08/2009
Signature of Drawing Officer & Designation(Office Seal)

For use of Treasury/ Bank

Name of Treasury/ Bank :