Date:

Name of Employee:

Employee number:

Employee Declaration for premium due in Feb & Mar 20__

I hereby declare that following insurance premiums are due in the month of
Feb & Mar 20__

Sr. Insurance details Policy Payment due Amt (Rs.)

No. Number Date
A Life Insurance Premium
1
2
3
4
5
6
B Mediclaim Insurance
1
2
3

Request you to consider the above listed details for income tax calculations.

I have attached previous years premium paid receipts for proofs. I will be
fully responsible for making the payments of the above mentioned insurance
premiums before 31st March 20__

In case the documents are required to be produced for verification, I will

produce the same as and when requested.

Signature of the employee