FORM B

KERALA STATE INSURANCE DEPARTMENT

Statement showing deductions towards State Life Insurance Policies
for the month of November 2013
DDO/SDO Code :

0703-280-

Name of Office :

TALUK HEADQUARTERS HOSPITAL KAYAMKULAM

Department

Health Services

Salary Head : 2210-01-110-99---

Mode of Payment (By Salary Deduction/Demand Draft/Challan) : ................................................................................................................................................

Details of Demand Draft/Challan : ...................................................................................................................................................................................................
SL No
1

PEN
619925

Name

Policy No.

ASISH B Dr

Premium

0KSID/Li/ 281115495
Total

Loan
Amount Instal. No.

Total

1000
1000

Remarks

1000
1000
(Rupees One Thousand only)

Place : Kayamkulam PO, Alappuzha Dist

(Office Seal)

Date : 05/12/2013

Spark Code : 38007499989897957999

Signature :
Name & Address
of DDO/SDO :

ASISH B Dr,
Assistant Surgeon,
TALUK HEADQUARTERS HOSPITAL
KAYAMKULAM,
Health Services