Andhra Pradesh Government Life Insurance

(Forms, Declaration, and Application)

INDEX

S. No. Title
1 Declaration Regarding Loss of Policy Form
2 Proposal Form
3 Application for Loan
4 Refund Form (Death Claim)
5 Refund Form (Other than Death Claim)
 Declaration regarding loss of policy

I ______________________________ S/o, D/o _________________________________hereby

declare that the policy/ies No. ______________________________ has/have been lost and not

mortgaged with any Bank, Firm, Third Party or any financial institution towards any loan.

Signature of subscriber

/Attested/

Signature of certifying Gazetted Officer

Name, Designation and Office seal
 APPLICATION FOR POLICY
FyÌÁ{qs µR¶LRiÆØxqsVò

Form – 1
FnyLRiLi c 1

DIRECTORATE OF INSURANCE
\® ²¶lLiNíRPlLiÉÞ A£msn B©«sW=lLi©±s=
GOVERNMENT OF ANDHRA PRADESH
ALiúµ³R¶ úxms®µ¶[a`P úxms˳ÁÏ V»R½*ª«sVV
HYDERABAD
\|¤¦¦¦µR¶LSËص`¶
DISTRICT INSURANCE OFFICE ___________
ÑÁÍýØ ÕdÁª«sW NSLSùÌÁ¸R¶Vª«sVV ___________
PROPOSAL FORM
úxms¼½FyµR¶©«s xmsú»R½ª«sVV
All Columns shall be filled in capitals only
@¬sõ NSÌÁª«sVVÌÁV |msµô¶R @ORPQLRiª«sVVÌÁ»][ xmspLjiògS ¬sLixmsª«sÛÍÁ©«sV
Policy No. ___________ Proposal Form No. ___________
FyÌÁ{qs ®©sLi. ___________ úxms¼½FyµR¶©«s ®©sLi. ___________
1. Name }msLRiV
Surname BLiÉÓÁ }msLRiV Full Name xmspLjiò }msLRiV 2. Sex Male / xmsoLRiVxtsv²R¶V
Female / {qsòQû

3. Father’s Name »R½Liú²T¶ }msLRiV 4. Designation x¤¦Ü[µy

5. Employee Office Address Dµ][ùgji NSLSùÌÁ¸R¶V ÀÁLRiV©yª«sW 6. Date of Birth xmsoÉíÁÓ ©«s ¾»½[µj¶ D D M M Y Y Y Y
(As per Service Register)
xqsLki*£qs LjiÑÁxtísQL`i úxmsNSLRiLi

P I N

7. Date of First Appointment ®ªsVVµR¶ÉÓÁ ¬s¸R¶Wª«sVNRPxmso ¾»½[µj¶ D D M M Y Y Y Y

8. Marital Status -sªyz¤¦¦¦»R½VÍØ / @-sªyz¤¦¦¦»R½VÍØ / -s»R½Li»R½Vªy / -s²yNRPVÌÁV

Married Unmarried Widow Divorced

9. If married, No. of Children and their ages zmsÌýÁÌÁ xqsLiÅÁù ª«s¸R¶VxqsV= (xqsLi. ÍÜ[)
-sªyz¤¦¦¦»R½V\ÛÍÁ¾»½[ zmsÌýÁÌÁ qx sLiÅÁù ª«sVLji¸R¶VV ªyLji ª«s¸R¶VxqsV=

10. Basic Pay and Pay Scale ª«sVWÌÁ ®ªs[»R½©«sª«sVV ª«sVLji¸R¶VV ®ªs[»R½©«sª«sVV }qsäÌÁV

11. DETAILS OF NOMINATION ©y-sV®©s[tx sQ©s« V -sª«sLSÌÁV

S. No. Name of Nominee Name of Nominee’s Father Age Relationship of Nominee Share
úNRPª«sV xqsLiÅÁù ©y-sV¬s }msLRiV ©y-sV¬s ¹¸¶VVNRPä »R½Liú²T¶ }msLRiV ª«s¸R¶VxqsV= ¿RÁLiµyµyLRiV¬sNTP ©yª«sV¬s»][ xqsLiÊÁLiµ³R¶Li ªyÉØ

12. Are you in Good Health úxmsxqsVò»½R Li -dsV AL][giR ùLi ËØgRiVgS ª«so©«sõµy ( ) Tick Yes / @ª«so©«sV No / NSµR¶V

(Contd – 2)
 :: 2 ::

13. Have you in the preceeding (3) years been absent on Leave on Yes / @ª«so©«sV No / NSµR¶V
Medical Grounds for more than (10) days at a
time ? If Yes, give details
gRi»R½ ª«sVW²R¶V qx sLiª«s»R½=LSÌÁÍÜ[ -dsVLRiV \®ªsµR¶ù NSLRißØÌÁ \|ms IZNP[ryLji (10) L][ÇÁÙÌÁNRPV \|msgS
|qsÌÁª«so \|ms \lgiLRiV¥¦¦¦ÇÁLRi¸R¶WùLS ? @LiVV¾»½[ A -sª«sLSÌÁV ¾»½ÌÁxmsLi²T¶
14. 1. Have you ever suffered from any of the following Diseases :-
C úNTPLiµj¶ }msL]ä©«sõ ªyùµ³R¶VÌÁÍÜ[ ®µ¶[¬s»][\®©s©y -dsVLRiV FsxmsöV\®²¶©y Ëص³R¶mx s²ïyLS ?

Fs. Heart Ailment gRiVLi®²¶ªyùµ³¶j Yes / @ª«so©«sV No / NSµR¶V

ÕÁ. Kidney ª«sVWú»R½zmsLi²R¶Li Yes / @ª«so©«sV No / NSµR¶V

zqs. Cancer NSù©«s=LRiV Yes / @ª«so©«sV No / NSµR¶V

²T¶. Lungs EzmsLji ¼½»R½VòÌÁV Yes / @ª«so©«sV No / NSµR¶V

2. If Yes, give details of Disease, duration and Treatment received

xqsª«sWµ³y©«sª«sVV @ª«so©«sV @LiVV©«s, ªyùµ³j¶ -sª«sLSÌÁV, ÀÁNTP»R½= ¼d½qx sVN]¬s©«s \®ªsµR¶ù }qsª«sÌÁ -sª«sLSÌÁV
¾»½ÌÁöLi²T¶

15. Are you a physically challenged person. If so, enclose Certificate issued Yes / @ª«so©«sV No / NSµR¶V
by a Competent Authority
-dsVNRPV G\®µ¶©y aSLkiLRiNRP ÍÜ[mx sLigS¬s \®ªsNRPùÌÁLigS¬s D©«sõQÈýÁLiVV¾»½[ @ÉíÁÓ @LigRi\®ªsNRPÌÁùLi -sª«sLSÌÁV ¾»½ÌÁxmsLi²T¶,
\®ªsµyùµ³j¶NSLji ÇØLki ¿Á[zqs©«s @LigRi\®ªsNRPÌÁùLi µ³R¶Xª«sxmsú»y¬sõ qx sª«sVLjiöLi¿RÁLi²T¶

16. If already insured Policy No. Total Monthly Premium

Bµj¶ª«sLRiZNP[ ÕdÁª«sW ¿Á[zqsD©«sõ¿][ FyÌÁ{qs ®©sLi. ®©sÌÁxqsLji ú{ms-sV¸R¶VL ®ªsVV»R½Lò i

17. Proposed Monthly Premium úxms¼½Fyµj¶LiÀÁ©«s ®©sÌÁxqsLji ú{ms-sV¸R¶VLi

18. Month and Year of Recovery »R½gæij Lixmso ÇÁLjigji©«s ®©sÌÁ ª«sVLji¸R¶VV xqsLiª«s»R½=LRiLi

19. Mobile No. ®ªsVV\ÛËÁÍÞ ®©sLi.

20. Email Address B®ªsVVLiVVÍÞ ÀÁLRiV©yª«sW 21. Aadhar Card No. Aµ³yL`i NSL`iï ®©sLi.

22. Employee ID No. Dµ][ùgji gRiVLjiòLixmso ®©sLi.

23. Major Head |msµôR¶ xmsµôR¶V Try. D. D. O. Code úÛÉÁÇÁLki ²T¶. ²T¶. J. N][²`¶

úxms¼½FyµR¶NRPV¬s LRiW²³¶T úxmsNRPÈÁ©«s

Declaration by the Proponent

"úxmsaRPõÌÁ©«sV xmspLjigS @LóiR Li ¿Á[qx sVNRPV©«sõ »R½LS*»R½ ®©s[©«sV \|ms©«s ¾»½ÖÁzms©«s -sª«sLRiª«sVVÌÁV Bª«s*²R¶ª«sVLiVVLiµj¶. @-s ©yxqs*µR¶qx sWòLij »][
úªyzqsLi\®µ¶©«s©«sV NSNRPF¡LiVV©«s©«sV úxms¼½ @LiaRPLi ¸R¶Vµ³yLóiR Li, xqsª«sVúgRiLi, xqsLixmspLñiR Li @LiVV©«sª«s¬s¸R¶VV G xmsLjizqós»R ½VÌÁNRPV xqsLiÊÁLiµ³j¶LiÀÁ ®©s[©«sV xqsª«sW¿yLRiª«sVV
@LiµR¶Â¿Á[¸¶R Vª«sÌÁzqs¸R¶VV©«sõµ][ A xmsLjizqós»R½VÌÁ©«sV ¬sÖÁzms®ªs[¸¶R VÛÍÁ[µR¶¬s¸R¶VV ÛÍÁ[µy LRix¤¦¦¦xqsùLigS ª«soLi¿RÁÛÍÁ[ µ¶R ¬s¸R¶VV ®©s[©«sV BLiµR¶V ª«sVWÌÁª«sVVgS úxmsNRPÉÓÁLi¿RÁV¿RÁV©yõ©«sV. \|ms
-sª«sLRißáÌÁV ª«sVLji¸R¶VV C úxmsNRPÈÁ©«s ÕdÁª«sW N]LRiNRPV úxms¼½Fyµj¶LiÀÁ©«s IxmsöLiµy¬sNTP úFy¼½xmsµj¶NRPÌÁVgS ª«soLi²yÌÁ¬s¸R¶VV ®©s[©«sV ÊÁVµô¶ðj mx spLRi*NRPLigS, G\®µ¶©y xqs»R½ù µR¶WLRi\®ªsV©«s
-sª«sLRißá©«sV ¿Á[zqs©«sÈýÁVgS¬s, ¾»½ÖÁ¸R¶VxmsLRi¿RÁª«sÌÁzqsª«so©«sõ G\®µ¶©y xmsLjizqós¼½¬s ®ªsWxqsxmso ÊÁVµô¶ðj »][ µyÀÁ ª«soLiÀÁ©«sÈýÁVgS¬s, BLiµR¶V-dsVµR¶ÈÁ NRP©«sVg]©«sõ ¹¸¶V²R¶ÌÁ xqsµR¶LRiV
NSLiúÉØNíRPV úNTPLiµR¶ ¿ÁÖýÁLiÀÁ¸R¶VV©«sõ ú{ms-sV¸R¶Vª«sVVÌÁ¬sõLiÉÓÁ¬s N][ÍÜ[öª«sÛÍÁ©«s¬s¸R¶VV, A IxmsöLiµR¶Li xqsLix mspLñiR LigS LRiµôR¶V NSª«sÌÁ©«s¬s¸R¶VV ®©s[©«sV IxmsöVN]©«sV¿RÁV©yõ©«sV."
(Contd – 3)
 :: 3 ::

“I do hereby declare that the foregoing details and Answers have been given by me after fully
understanding the questions, the same are true, full and complete whether written in my own hand writing or not in
every particular and that I have not withheld or concealed any circumstances with regard to which information has
been required from me. I agree that the foregoing statements and declaration shall be the basis of the proposed
contract for an Insurance and that if it shall hereafter appear that I have willfully made any untrue statement or
have fraudulently concealed any circumstances which I ought to have made known then all the Premia which shall
have been paid under the said contract shall be forfeited and the contract rendered absolutely null and void.”

¾»½[µj¶ ÒÁ-s»R½ ÕdÁª«sW ¿Á[¸¶R VµR¶ÌÁÀÁ©«s ª«sùQQNTPò xqsLi»R½NRPLi

Date Signature

úxms¼½FyµR¶©«s \|ms G @µ³j¶NSLji xqsª«sVORPQLiÍÜ[ xqsLi»R½NRPLi ¿Á[¸R¶VÊÁ²T¶©«sµ][ A @µ³j¶NSLji µ³¶R X-dsNRPLRißá xmsú»R½Li
CERTIFIED BY OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED

|\ ms©«s }msL]ä©«sõ xqsLki*xqsV -sª«sLSÌÁV xqsLji\¹¸¶V©«sª«s¬s¸R¶VV, úxms¼½FyµR¶NRPV²R¶V ©y xqsª«sVORPQLiÍÜ[ xqsLi»R½NRPLi ¿Á[zqs©y²R¶¬s¸R¶VV ®©s[©«sV
µ³R¶Xª«sxmsLRiVxqsVò©«s©y©«sV. ©«sW»R½©«s / @µR¶©«sxmso ÕdÁª«sW ¬s-sV»R½ªò «sVV »R½gæij Lixmso ¿Á[zqs©«s ®ªsVVµR¶ÉÓÁ ú{ms-sV¸R¶VLi LRiW. ________________ ª«sVLji¸R¶VV ®ªsVV»R½ªò «sVV
LRiW. ___________ (Bµj¶ ª«sLRiZNP[ »R½gæij Lixmso ¿Á[zqs©«s ª«sVLji¸R¶VV úxmsxqsVò»½R ú{ms-sV¸R¶VLi NRPÌÁVxmsoN]¬s) ___________ ®©sÌÁ ª«sVLji¸R¶VV ___________
xqsLiª«s»R½=LRiª«sVV ®ªs[»½R ©«sª«sVV ©«sVLi²T¶ ¾»½[µj¶ ___________ gRiÌÁ ÉÜ[NRP©±s ®©sLiÊÁLRiV ___________ µy*LS ª«sxqsWÌÁV ¿Á[¸¶R V²R¶ª«sVLiVV©«sµj¶.

I certify that the service particulars stated above are correct and the Proponent’s Signature has
been affixed in my presence. The First Premium recovered for fresh /subsequent Insurance is ___________ in
all _____________ (including previous and present Premium) from the pay of _________________ month and
_____________ year, vide token No. ____________ dated __________________

xqósÌÁLi xqsLi»R½NRPª«sVV
Station Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²R¶ @µ³j¶NSLji (Ax¤¦¦¦LRißá ª«sVLji¸R¶VV
ÊÁÉØ*²R¶ @µ³j¶NSLji gRiÑÁÛÉÁ²`¶ NS¬s ¹¸¶V²R¶ÌÁ A \|ms gRiÑÁÛÉÁ²`¶
¾»½[µj¶ @µ³j¶NSLji xqsLi»R½NRPª«sVV ¿Á[¸¶R Vª«sÌÁ¸R¶VV©«sV. ª«sVLji¸R¶VV {qs*¸R¶V
Date µ³R¶X-dsNRPLRißá ¿ÁÌýÁµR¶V.)

For OFFFICE USE Signature

O.R. ( ) Drawing and Disbursing Officer (If DDO is
not gazetted, it should be countersigned
by next Gazetted Officer and Self
Attestation is not acceptable)

x¤¦Ü[µy
Designation

NSLSùÌÁ¸R¶V ª«sVVúµR¶
Office Seal

Supdt. DIO

Please visit our Website : www.apgli.ap.gov.in for further information and guidelines
 01/2014

LOAN FORM
ÊÁVVßá µ³R¶LRiÆØxqsVò
Form No. 29
©«sª«sVW©y ®©sLi. 29
Inward No.
@Li»R½LæS-sV ®©sLi.

APGLI Office Use Only

NSLSùÌÁ¸R¶Vxmso Dxms¹¸¶WgSLóiR Li
DIRECTORATE OF INSURANCE
\®²¶lLiNíRPlLiÉÞ A£msn B©«sW=lLi©±s=
GOVERNMENT OF ANDHRA PRADESH
ALiúµ³R¶ úxms®µ¶[a`P úxms˳ÁÏ V»R½*ª«sVV, ALiúµ³R¶ úxms®µ¶[a`P
HYDERABAD, Andhra Pradesh
\|¤¦¦¦µR¶LSËص`¶
District Insurance Office : __________
ÑÁÍýØ ÕdÁª«sW NSLSùÌÁ¸R¶VLi iM __________
APPLICATION FOR LOAN
ÊÁVVß᪫sVV N]LRiNRPV µR¶LRiÆØxqsVò
Policy No.
FyÌÁ{qs ®©sLi.
1. Name of the Subscriber ¿RÁLiµyµyLRiV¬s }msLRiV

2. Father’s Name »R½Liú²T¶ }msLRiV 3. Designation ¤x ¦Ü[µy

4. Date of Birth xmsoÉíÁÓ ©«s ¾»½[µj¶ D D M M Y Y Y Y

(As per Service Register)
xqsLki*£qs LjiÑÁxtísQL`i úxmsNSLRiLi
5. Office where he is employed Dµ][ùgji xms¬s ¿Á[¸R¶VV¿RÁV©«sõ NSLSùÌÁ¸R¶VLi }msLRiV D. D. O. Code ²T¶. ²T¶. J. N][²`

6. The Amount of Loan applied for µR¶LRiÆØxqsVò ¿Á[qx sVN]©«sõ ÊÁVVßá ®ªsVV»R½Lò i

7. The Number of Instalments in which the Loan is proposed to be repaid ( ) 12 24 36 48

(Not exceeding 48, according to Rule 46)
ÊÁVVßá ®ªsVV»R½Lò i ¼½Ljigji ¿ÁÖýÁLi¿RÁµR¶ÌÁÀÁ©«s úxms¼½Fyµj¶»R½ ªyLiVVµyÌÁ qx sLiÅÁù (¬s¸R¶Vª«sWª«s×Á 46 úxmsNSLRiLi 48 ªyLiVVµyÌÁNRPV -sVLi¿RÁLSµR¶V)

8. Basic Pay ª«sVWÌÁ ®ªs[»½R ©«sLi Pay Scale ÒÁ»R½mx so }qsäÌÁV

9. Gross Salary Total Deductions Net Salary

ÒÁ»R½ª«sVV ®ªsVV»R½Lò i ®ªsVV»R½Lò i »R½gæij LixmsoÌÁV ¬sNRPLRi ÒÁ»R½Li

10. Monthly Premium ®©sÌÁxqsLji ú{ms-sV¸R¶Vª«sVV ®ªsVV»R½Lò i

11. Name of the Bank where Payment of Loan is desired

LRiVßá ®ªsVV»R½ªò «sVV ¿ÁÖýÁLixmso N][LiR V¿RÁV©«sõ ËØùLiN`P }msLRiV

Branch Name úËØLiÀÁ }msLRiV

IFS CODE H Fs£mns ¸R¶V£qs N][²`¶

Bank Account No. ËØùLiNRPV ÆØ»y ®©sLiÊÁLRiV

(Contd – 2)

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 :: 2 ::

12. Employee I. D. No. Dµ][ùgji H²T¶ ®©sLiÊÁLRiV

13. Aadhar Card No. Aµ³yL`i NSL`ïi ®©sLiÊÁLRiV

14. Mobile No. ®ªsVV\ÛËÁÍÞ ®©sLiÊÁLRiV

15. E – Mail of Policyholder FyÌÁ{qsµyLRiV¬s C c ®ªsVVLiVVÍÞ

16. Mobile No. of Drawing and Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²R¶ @µ³j¶NSLji ®ªsVV\ÛËÁÍÞ ®©sLiÊÁLRiV
Disbursing Officer

17. E – Mail of Drawing and Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²R¶ @µ³j¶NSLji C c ®ªsVVLiVVÍÞ

Disbursing Officer

I hereby declare that the particulars stated above are true and correct.

\|ms ¾»½ÖÁzms©«s -sª«sLSÌÁV, xqs\lLi©«s®ªs[©«s¬s LiVVLiµR¶Vª«sVWÌÁª«sVVgS µ³R¶X-dsNRPLjiLi¿RÁV¿RÁV©yõ©«sV.

I hereby authorise the Director of Insurance, Government of Andhra Pradesh to pass orders to
effect recoveries of Loans and Interest from my salary in the manner as may be prescribed by him in
accordance with the Rules of APGLI Fund.

ÒÁ-s»R½ ÕdÁª«sW aSÅÁ ¬s¸R¶Vª«sWÌÁ úxmsNSLRiLi, ÕdÁª«sW aSÅÁ \®²¶lLiNíPR LRiV ¬slLôib[ PLiÀÁ©«s Lki¼½ÍÜ[ ª«s²ïU¶»][ FyÈÁV ÊÁVVßá ®ªsVV»yò¬sõ ©y ÒÁ»R½Li
©«sVLi²T¶ ¼½Ljigji ª«sxqsWÌÁV ¿Á[}qsLiµR¶V\ZNP »R½gRiV D»R½òLRiV*ÌÁV ÇØLki ¿Á[¸R¶V²y¬sNTP ALiúµ³¶R úxms®µ¶[a`P úxms˳ÁÏ V»R½* ÕdÁª«sW aSÅÁ \®²¶lLiNíPR LRiVNRPV @µ³j¶NSLRi-sVxqsVò©yõ©«sV.

Date : Signature of Applicant

¾»½[µj¶ iM µR¶LRiÆØxqsVòµyLRiV¬s xqsLi»R½NRPª«sVV

It is certified that the particulars stated in the above application are correct to the best of my
knowledge and belief and the above Signature of Sri ___________________ is signed in my presence. He
obtained a Loan of _______________ from APGLID out of which ______________ is still
outstanding.

\|ms µR¶LRiÆØxqsVòÍÜ[ ¾»½ÖÁzms©«s -sª«sLSÌÁV ©yNRPV ¾»½ÖÁzqs©«sLi»R½ª«sLRiNRPV ª«sVLji¸R¶VV -saRP*bPLiÀÁ©«s ®ªs[VLRiNRPV xqs\lLi©«s®ªs[©«s¬s LiVVLiµR¶Vª«sVWÌÁª«sVVgS
µ³R¶X-dsNRPLjiLi¿RÁV¿RÁV©yõ©«sV. $ ___________________ \|ms µR¶LRiÆØxqsVò \|ms xqsLi»R½NRPª«sVV ©y xqsª«sVORPQª«sVVÍÜ[ ¿Á[aSLRiV. C¸R¶V©«s ÕdÁª«sW aSÅÁ ©«sVLi²T¶
gRi»R½LiÍÜ[[ ___________________ LRiVß᪫sVV F~Liµj¶ª«so©yõLRiV. C ®ªsVV»R½ªò «sVV ©«sVLi²T ___________________ LiVVLiNS
 ¿ÁÖýÁLi¿RÁª«sÌÁzqsª«so©«sõµj¶.

Signature of Drawing and Disbursing

Officer with Seal
Station :
xqósÌÁª«sVV iM Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²R¶ @µ³j¶NSLji xqsLi»R½NRPª«sVV
NSLSùÌÁ¸R¶V ª«sVVúµR¶»][
Date : Name :
(In Block Letters)
¾»½[µj¶ iM }msLRiV iM
(Contd – 3)

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 :: 3 ::

1/-

Revenue Stamp
lLi®ªs©«sWù ríyLi£ms

STAMP RECEIPT
LRibdPµR¶V

Note : If the Amount exceeds 5,000/-, Revenue Stamp shall be affixed.

gRiª«sV¬sNRP iM \|msNRPLi 5,000/c ÌÁNRPV -sVLiÀÁ©«sÈýÁLiVV¾»½[ ríyLixmso @¼½NTPLi¿yÖÁ

Policy No. ___________

FyÌÁ{qs ®©sLiÊÁLRiV iM ___________

I ______________________ have received a sum of _______________ (Rupees

___________________________________________________________ Only) from Directorate of Insurance,
Andhra Pradesh, Hyderabad vide Cheque / D. D. / Online Payment No. ___________________ dated :
______________ towards sanction of Loan / Settlement of Claim against my Policies.

$ / $ª«sV¼½ ______________________ @©«sV ®©s[©«sV ÒÁ-s»R½ ÕdÁª«sW aSÅÁ \®²¶lLiNíPR lLi[ÈÁV, \|¤¦¦¦µR¶LSËصR¶V ªyLji ©«sVLi²T¶
________________ (LRiWFy¸R¶VÌÁV __________________________________________________________
ª«sWú»R½®ªs[V) ¾»½[µj¶ iM ______________________ ®©sLiÊÁLRiV ______________________ gRiÌÁ ¿ÁNRPVä / ²T¶. ²T¶. / A©±s \ÛÍÁ©±s }ms®ªsVLiÉÞ
µy*LS @LiµR¶VN]©«sõÈýÁV BLiµR¶Vª«sVWÌÁª«sVVgS LRibdPµR¶V @LiµR¶Â¿Á[qx sVò©yõ©«sV.

Signature
xqsLi»R½NRPª«sVV

I hereby certify that the above Signature of Sri / Smt ________________________________

is made in my presence.

$ / $ª«sV¼½ _____________________________________ ¿Á[zqs©«s \|ms xqsLi»R½NRPª«sVV ©y xqsª«sVORPQª«sVVÍÜ[ ¿Á[aSLRi¬s

µ³R¶X-dsNRPLjiLi¿RÁV¿RÁV©yõ©«sV.

Station : Signature of Drawing and Disbursing

xqósÌÁª«sVV iM Officer with Seal
Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²R¶ @µ³j¶NSLji xqsLi»R½NRPª«sVV
NSLSùÌÁ¸R¶V ª«sVVúµR¶»][

Date : Name :
¾»½[µj¶ iM }msLRiV iM

Designation :
x¤¦Ü[µy iM

Visit Our Website : www.apgli.ap.gov.in

 01/2014

DEATH CLAIM FORM

ª«sVLRißá ZNýPLiVVª±sV FnyLRiLi
Please affix Legal Heir
Photo, duly attested by Inward No.
the DDO
@Li»R½LæS-sV ®©sLi.
ÌÁÕôÁµyLRiV¬s Fn~ÉÜ @¼½NTPLiÀÁ
µ³R¶X-dsNRPLjiLi¿RÁ ª«sÛÍÁ©«sV
Office Use Only
APGLI NSLSùÌÁ¸R¶Vxmso Dxms¹¸¶WgSLóiR Li
DIRECTORATE OF INSURANCE
\® ²¶lLiNíRPlLiÉÞ A£msn B©«sW=lLi©±s=
GOVERNMENT OF ANDHRA PRADESH
ALiúµ³R¶ úxms®µ¶[a`P úxms˳ÁÏ V»R½*ª«sVV
HYDERABAD
\|¤¦¦¦µR¶LSËص`¶
Refund Form – 2
Ljimx nsLi²`¶ FnyLRiLi c 2

DISTRICT INSURANCE OFFICE ___________

ÑÁÍýØ ÕdÁª«sW NSLSùÌÁ¸R¶Vª«sVV ___________
(To be filled by the Heir of the Subscriber)
(¿RÁLiµyµyLRiV ªyLRixqsVÌÁV ˳ÁÏ Lkiò ¿Á[¸¶R Vª«sÛÍÁ©«sV)
All Columns shall be filled in capitals only
@¬sõ NSÌÁª«sVVÌÁV |msµô¶R @ORPQLRiª«sVVÌÁ»][ xmspLjiògS ¬sLixmsª«sÛÍÁ©«sV
Policy No. Employee ID No. Claimant’s Mobile No.
FyÌÁ{qs ®©sLi. Dµ][ùgji H²T¶ ®©sLiÊÁLRiV ÌÁÕôÁµyLRiV¬s ®ªsVV\ÛËÁÍÞ ®©sLiÊÁLRiV

1. Name of the Subscriber ¿RÁLiµyµyLRiV¬s }msLRiV

2. Father’s Name »R½Liú²T¶ }msLRiV 3. Designation ¤x ¦Ü[µy

4. Name of the Office and the District where the Subscriber was working at the
time of Death
¿RÁLiµyµyLRiV ¿RÁ¬sF¡¹¸¶V©yÉÓÁNTP xms¬s¿Á[zqs©«s NSLSùÌÁ¸R¶Vª«sVV }msLRiV, ÑÁÍýØ }msLRiV

5. Date of death of the subscriber specifying the

D D M M Y Y Y Y
disease / cause of death
¿RÁLiµyµyLRiV ¿RÁ¬sF¡LiVV©«s ¾»½[µj¶, ªyùµ³j¶ -sª«sLRiª«sVVÌÁV

6. Name of the Claimant and his / her Father’s Name Relationship with deceased Policy holder
ZNýPLiVVª«sVV ¿Á[¸R¶VV¿RÁV©«sõ ªyLji }msLRiV ª«sVLji¸R¶VV ªyLji »R½Liú²T¶ }msLRiV ¿RÁ¬sF¡LiVV©«s ¿RÁLiµyµyLRiV¬s»][ gRiÌÁ ÊÁLiµ³R¶V»R½*Li

7. Date and reason of retirement

D D M M Y Y Y Y
xmsµR¶-ds -sLRiª«sVßá ¾»½[µj¶, NSLRiß᪫sVVÌÁV

(Contd – 2)
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 :: 2 ::

8. Names of the Wife or Wives of the deceased with their

children and ages
¿RÁ¬sF¡LiVV©«s ª«sùQQNTPò ¹¸¶VNRPä ˳ØLRiù ÛÍÁ[µy ˳ØLRiùÌÁ }msLýiR V, zmsÌýÁÌÁ }msLýiR V ª«sVLji¸R¶VV ª«s¸R¶VxqsV=

9. Name of the Bank where payment is desired

¿ÁÖýÁLixmso N][LiR V¿RÁV©«sõ ËØùLiN`P }msLRiV

Branch Name úËØLiÀÁ }msLRiV

IFS CODE H Fs£mns ¸R¶V£qs N][²`¶

Bank Account No. ËØùLiNRPV ÆØ»y ®©sLiÊÁLRiV

Mobile No. of Claimant ÌÁÕôÁµyLRiV¬s ®ªsVV\ÛËÁÍÞ ®©sLiÊÁLRiV

Aadhar Card No. Aµ³yL`i NSL`ïi ®©sLiÊÁLRiV

10. Full Address of Claimant with Pin Code

ÌÁÕôÁµyLRiV¬s xmspLjiò ÀÁLRiV©yª«sW zms©±s N][²`¶ »][ xqs¥¦¦¦

Important Note : In case of dispute the claim will be settled in terms of Rule 32 (d) (3) of Andhra Pradesh
Government Life Insurance Fund Rule.

ª«sVVÅÁùgRiª«sV¬sNRP iM G®µ¶[¬s -sªyµR¶ª«sVV D©«sõ¹¸¶V²R¶ÌÁ C aSÅÁ ¹¸¶VVNRPä ¬sÊÁLiµ³¶R ©«s 32 (²T¶) (3) úxmsNSLRiLi ¿ÁÖýÁLixmso xmsLjitx sQäLjiLi¿RÁÊÁ²R¶V©«sV.

DECLARATION
úxmsNRPÈÁ©«s
I do hereby declare that there are no other widow or widows of the deceased or minor sons
and unmarried daughters born of them except those mentioned in this Application. If in future any other
Claimants or minor heirs mentioned in the Application Claim payment of their share in the amount on attaining
majority, I shall be held responsible to repay the amount. I also declare that if in future it is found that any
excess payment was made to me in adversantly, I agree to repay such excess amount.

C µR¶LRiÆØxqsVòÍÜ[ ¾»½ÌÁVxmsÊÁ²T¶©«s ªyLRiV ÛÍÁ[NRP ¿RÁ¬sF¡LiVV©«s ª«sùQQNPT Nò PT -s»R½Li»R½Vª«so ÛÍÁ[µy -s»R½Li»R½Vª«soÌÁV ÛÍÁ[µy ªyLjiNTP NRPÖÁgji©«s \®ªsV©«sLRiV
N]²R¶VNRPVÌÁV |msLi²ýT¶ NS¬s NRPVª«sWlLiòÌÁV Fsª«sLRiV Û ÍÁ[LRi¬s BLiµR¶Vª«sVWÌÁª«sVVgS úxmsNRPÉÓÁLi¿RÁ²R¶\®ªsV©«sµj¶. B»R½LRi x¤¦¦¦NRPVäµyLýiR V ÛÍÁ[µy C µR¶LRiÆØxqsVòÍÜ[ ¾»½ÌÁVxmsÊÁ²T¶©«s \®ªsV©«sLRiV
ªyLRixqsVÌÁV ®ªs[VÇÁLýiR V @LiVV©«s -dsVµR¶ÈÁ C \|msNRPª«sVVÍÜ[ »R½ª«sV ªyÉØ©«sV ˳ÁÏ xtsQù»R½VòÍÜ[ N][LiR V xmsORPQª«sVVÍÜ[ A ®ªsVV»R½ªò «sVV©«sV ¼½Ljigji ¿ÁÖýÁLi¿RÁVÈÁNRPV ®©s[©«sV Ëص³¶R Vù²R¶\®©s
DLi²R¶gRiÌÁ©«sV. INRP®ªs[ÎÁÏ F~LRiFyÈÁV©«s G\®ªsV©y FsNRPV䪫s ®ªsVV»R½ªò «sVV F~Liµj¶¸R¶VV©«sõ ¹¸¶V²R¶ÌÁ @ÉíÁÓ ®ªsVV»R½ªò «sVV©«sV ¼½Ljigji ¿ÁÖýÁLi¿RÁVÈÁNRPV Ëص³R¶ù»R½ ª«sz¤¦¦¦Li»R½V©«s¬s
BLiµR¶Vª«sVWÌÁª«sVVgS úxmsNRPÉÓÁLi¿RÁV¿RÁV©yõ©«sV.

Signature or / Left Hand Thumb Impression of the Applicant

µR¶LRiÆØxqsVòµyLRiV xqsLi»R½NRPª«sVV / ú®ªs[ÖÁ ª«sVVúµR¶
CERTIFICATE
xqsLíjizmnsZNPÉÞ
Certified that the entries made in the Application are correct, the details of which are known
to me. There is no other legal heir of the deceased except those mentioned in the Application and the Signature
or Thump – Impression is of Sri / Smt _________________________________________________________
widow of / guardian of _____________________________________________________________ regarding
which I am fully satisfied.

It is also certified that the last working days Salary was paid to the Claimant only and the
deceased Subscriber was in Service till death.

The Subscriber obtained a Loan of ________________ against his APGLI Policy and if
any outstanding Loan or Interest is payable, the same can be recovered from the Policy amount.

(Contd – 3)

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 :: 3 ::
µR¶LRiÆØxqsVòÍÜ[ ¿Á[zqs©«s ©«s®ªsWµR¶VÌÁV xqsúNRPª«sV\®ªsV©«sª«s¬s¸R¶VV, A -sª«sLRiª«sVVÌÁV ®©s[©«sV FsLjigji©«s®ªs[©«s¬s¸R¶VV µ³¶R X-dsxmsLRi¿RÁ²R¶ \®ªsV©«sµj¶. C
µR¶LRiÆØxqsVòÍÜ[ ¾»½ÌÁVxmsÊÁ²T¶©«s ªyLRiV ©yù¸R¶VÊÁµôR¶\®ªsV©«s B»R½LRi ªyLRiqx sVÌÁV Fsª«s*LRiW ÛÍÁ[LRi¬s¸R¶VW xqsLi»R½NRPª«sVV ÛÍ Á[µy ú®ªs[ÖÁ ª«sVVúµR¶
$ / $ª«sV¼½ _____________________________________________________________ -s»R½Li»R½Vª«so / xqsLiLRiORPQNRPV²R¶V
@LiVV©«s ______________________________________________ ®µ¶[ ©«s¬s¸R¶VV ©yNRPV xmspLjiògS xqsLi»R½Xzmsò NRPÖÁgji©«sµj¶. »R½µR¶VxmsLji
¿RÁLiµyµyLRiV¬s ÀÁª«sLji L][ÇÁÙÌÁ ÒÁ»R½ ˳ÁÏ »R½ùª«sVVÌÁV úxmsxqsVò»½R ÌÁÕôÁµyLRiV¬sNTP ¿ÁÖýÁLi¿RÁ²R¶ª«sVLiVV©«sµR¶¬s ª«sVLji ¸R¶VV ¿RÁ¬sF¡LiVV©«s ¾»½[µj¶ ª«sLRiNRPV xqsLki*xqsVÍÜ[®©s[ D©yõ²R¶¬s
µ³R¶X-dsNRPLjiLi¿RÁV¿RÁV©yõ©«sV.

Signature of the Drawing and Disbursing Officer

Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²y @µ³j¶NSLji xqsLi»R½NRPª«sVV

Name of the Officer

in Block Letters :
Office Seal -s²T¶ @ORPQLRiª«sVVÌÁÍÜ[ @µ³j¶NSLji }msLRiV
NSLSùÌÁ¸R¶VLi ª«sVVúµR¶

Designation :
x¤¦Ü[µy M

Name of the Office :

NSLSùÌÁ¸R¶V }msLRiV M

Note :- 1. The Application should be certified by the concerned Drawing and Disbursing Officer only.

gRiª«sV¬sNRP iMc 1. C µR¶LjiÆØxqsVò©«sV xqsLiÊÁLiµ³j¶»R½ Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²y @µ³j¶NSLji ª«sWú»R½®ªs[V µ³R¶X-dsNRPLjiLi¿RÁª«sÛÍÁ©«sV.
2. If the Subscriber dies with (3) Years of issue of Policy / Policies, the Drawing and Disbursing Officer
shall furnish the details of Leave on Medical Grounds availed for a period of (3) Years (alongwith
attested Xerox Copies of Medical Certificate) proceeding the date of commencement of Policy /
Policies.

2. ¿RÁLiµyµyLRiV²R¶V FyÌÁ{qs úFyLRiLi˳ÁÏ xmso ¾»½[µj¶ ©«sVLi²T¶ (3) xqsLiª«s»R½=LRiª«sVVÍÜ[mx so ª«sVLRißÓáLiÀÁ©«s¹¸¶V²R¶ÌÁ, Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²y @µ³j¶NSLji,
xqsµR¶LRiV ¿RÁLiµyµyLRiV²R¶V FyÌÁ{qs úFyLRiLi˳ÁÏ xmso ¾»½[µj¶NTP ª«sVW²R¶V xqsLiª«s»R½=LRiª«sVVÌÁ NSÌÁª«sVV©«sNRPV \®ªsµR¶ù NSLRiß᪫sVVÌÁ \|ms ªy²R¶VN]¬s©«s |qsÌÁª«so
-sª«sLRiª«sVVÌÁ©«sV (µ³R¶X-dsNRPLjiLiÀÁ©«s ÑÁLSN`P= \®ªsµR¶ù xqsLíij zmnsZNPÉÞ ÌÁ»][) »R½mx sö¬s xqsLjigS, C µR¶LSÆØxqsVò»][ xmsLixmsª«sÛÍÁ©«sV.
3. The following documents also shall be compulsorily enclosed.

3. µj¶gRiVª«s ¾»½ÖÁzms©«s mx sú»R½ª«sVVÌÁV NRPW²y »R½xmsöNRP ÇÁ»R½ ¿Á[¸¶R Vª«sÛÍÁ©«sV.

Enclosures :
ÇÁ»R½ ¿Á[¸¶R Vª«sÌÁzqs©«s :

a). Policy Bonds Original

Fs). FyÌÁ{qs xmsú»R½ª«sVV

b). Legal Heirs Certificate Copy duly attested

ÕÁ). ªyLRixqs»R½*xmso mx sú»R½ª«sVV µ³R¶X-dsNRPLRißá»][

c). Death Certificate Copy duly attested

zqs). ª«sVLRißá µ³R¶X-dsNRPLRißá xmsú»R½ª«sVV µ³R¶X-dsNRPLRißá»][

(Contd – 4)

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 :: 4 ::

1/-

Revenue Stamp
lLi®ªs©«sWù ríyLi£ms

STAMP RECEIPT
LRibdPµR¶V

Note : If the Amount exceeds 5,000/-, Revenue Stamp shall be affixed.

gRiª«sV¬sNRP iM \|msNRPLi 5,000/c ÌÁNRPV -sVLiÀÁ©«sÈýÁLiVV¾»½[ ríyLixmso @¼½NTPLi¿yÖÁ

Policy No. ___________

FyÌÁ{qs ®©sLiÊÁLRiV iM ___________

I ______________________ have received a sum of _______________ (Rupees

___________________________________________________________ Only) from Directorate of Insurance,
Andhra Pradesh, Hyderabad vide Cheque / D. D. / Online Payment No. ___________________ dated :
______________ towards sanction of Loan / Settlement of Claim against my Policies.

$ / $ª«sV¼½ ______________________ @©«sV ®©s[©«sV ÒÁ-s»R½ ÕdÁª«sW aSÅÁ \®²¶lLiNíRPlLi[ÈÁV, \|¤¦¦¦µR¶LSËصR¶V ªyLji ©«sVLi²T¶
________________ (LRiWFy¸R¶VÌÁV __________________________________________________________
ª«sWú»R½®ªs[V) ¾»½[µj¶ iM ______________________ ®©sLiÊÁLRiV ______________________ gRiÌÁ ¿ÁNRPVä / ²T¶. ²T¶. / A©±s \ÛÍÁ©±s }ms®ªsVLiÉÞ
µy*LS @LiµR¶VN]©«sõÈýÁV BLiµR¶Vª«sVWÌÁª«sVVgS LRibdPµR¶V @LiµR¶Â¿Á[qx sVò©yõ©«sV.

Signature
xqsLi»R½NRPª«sVV

I hereby certify that the above Signature of Sri / Smt ________________________________

is made in my presence.

$ / $ª«sV¼½ _____________________________________ ¿Á[zqs©«s \|ms xqsLi»R½NRPª«sVV ©y xqsª«sVORPQª«sVVÍÜ[ ¿Á[aSLRi¬s

µ³R¶X-dsNRPLjiLi¿RÁV¿RÁV©yõ©«sV.

Station : Signature of Drawing and Disbursing

xqósÌÁª«sVV iM Officer with Seal
Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²R¶ @µ³j¶NSLji xqsLi»R½NRPª«sVV
NSLSùÌÁ¸R¶V ª«sVVúµR¶»][
Date : Name :
¾»½[µj¶ iM }msLRiV iM

Designation :
x¤¦Ü[µy iM

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 01/2014

CLAIM FORM
ZNýPLiVVª±sV µ³R¶LRiÆØxqsVò
Form No. 12
©«sª«sVW©y ®©sLi. 12
Inward No.
@Li»R½LæS-sV ®©sLi.

APGLI Office Use Only

NSLSùÌÁ¸R¶Vxmso Dxms¹¸¶WgSLóiR Li
DIRECTORATE OF INSURANCE
\®²¶lLiNíRPlLiÉÞ A£msn B©«sW=lLi©±s=
GOVERNMENT OF ANDHRA PRADESH
ALiúµ³R¶ úxms®µ¶[a`P úxms˳ÁÏ V»R½*ª«sVV, ALiúµ³R¶ úxms®µ¶[a`P
HYDERABAD, Andhra Pradesh
\|¤¦¦¦µR¶LSËص`¶
Refund Form No. 1 District Insurance Office : __________
Ljimx nsLi²`¶ FnyLRiLi ®©sLi. 1 ÑÁÍýØ ÕdÁª«sW NSLSùÌÁ¸R¶VLi iM __________
APPLICATION FOR REFUND OF AMOUNT FROM THE DIRECTORATE OF INSURANCE, HYDERABAD
(To be filled by the Subscriber)
ÕdÁª«sW aSÅÁ \®²¶lLiNíRPlLi[ÈÁV NSLSùÌÁ¸R¶VLi, \|¤¦¦¦úµyËصR¶V ©«sVLi²T¶ ®ªsVV»R½òLi ªyxmsxqsVN][LRiV»R½V©«sõQÉÁíÓ µR¶LRiÆØxqsVò
(µk¶¬s¬s ¿RÁLiµyµyLRiV xmspLjiò ¿Á[¸R¶WÖÁ)
Policy No.
FyÌÁ{qs ®©sLi.

1. Name of the Subscriber ¿RÁLiµyµyLRiV¬s }msLRiV

2. Father’s Name »R½Liú²T¶ }msLRiV 3. Designation ¤x ¦Ü[µy

4. Name of the Office and the District where the Subscriber was last in Service
¿RÁLiµyµyLRiV xqsLki*xqsV ÀÁª«sLji L][ÇÁÙÌÁÍÜ[ xms¬s¿Á[zqs©«s NSLSùÌÁ¸R¶Vª«sVV }msLRiV, ÑÁÍýØ }msLRiV
5. Date of Maturity D D M M Y Y Y Y 6. Date of Birth D D M M Y Y Y Y
FyÌÁ{qs xmsLjißá¼½ ¾»½[µj¶ xmsoÉíÁÓ ©«s ¾»½[µj

7. a) Date of Retirement
D D M M Y Y Y Y
Fs) xmsµR¶-s -sLRiª«sVßá ¾»½[µj¶

Nature of Retirement ( ) Superannuation Voluntary Compulsory

xmsµR¶-s -sLRiª«sVßá xqs*˳ت«sLi xqsWxmsLS©«sVù¹¸¶[VxtsQ©±s xqs*¿RÁèéLiµR¶ ¬sLRi÷Liµ³R¶
b) Month of last deduction of Premium
ÕÁ) ú{ms-sV¸R¶VLi ®ªsVV»yò¬sõ ª«sxqsWÌÁV ¿Á[zqs©«s ÀÁª«sLji ¾®©sÌÁ

8. Name of the Bank where payment is desired

¿ÁÖýÁLixmso N][LiR V¿RÁV©«sõ ËØùLiN`P }msLRiV

Branch Name úËØLiÀÁ }msLRiV

IFS CODE H Fs£mns ¸R¶V£qs s N][²`¶

Bank Account No. ËØùLiNRPV ÆØ»y ®©sLiÊÁLRiV

(Contd – 2)
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 :: 2 ::

9. Employee I. D. No. Dµ][ùgji H²T¶ ®©sLiÊÁLRiV

10. Mobile No. ®ªsVV\ÛËÁÍÞ ®©sLiÊÁLRiV

11. Aadhar Card No. Aµ³yL`i NSL`ïi ®©sLiÊÁLRiV

12. Office in which the subscriber has worked during the last (5) years
¿RÁLiµyµyLRiV ÀÁª«sLji (5) GÎýÁÏ § xms¬s ¿Á[zqs©«s NSLSùÌÁ¸R¶VLi }msLRiV

13. Full Address of the Applicant with Pin Code

µR¶LRiÆØxqsVò µyLRiV xmspLjiò ÀÁLRiV©yª«sW zms©±s N][²`¶ »][ xqs¥¦¦¦

14. A) I have obtained __________ towards A. P. G. L. I. Loan and there is a balance ____________
to be paid which may be recovered alongwith interest from my Policy amount
Fs) _____________ G. zms. ÑÁ. FsÍÞ. H. ©«sVLi²T¶ ÊÁVVßáLi F~Liµj¶ª«so©yõ©«sV. C ®ªsVV»yò¬sNTP gS©«sV, _____________
¿ÁÖýÁLi¿RÁª«sÌÁzqs ª«so©«sõµj¶. C ®ªsVV»yò¬sõ ª«s²ïU¶»][ xqs¥¦¦¦ ©y FyÌÁ{qs ®ªsVV»R½Lò i ©«sVLi²T¶ ª«sxqsWÌÁV ¿Á[qx sVN]©«sª«s¿RÁVè©«sV

14. B) I do hereby declare that if in future it is found that any excess payment was made to me in advertantly,
I shall be held responsible to repay such excess amount and give my consent for deduction of the same
from my Pension.
ÕÁ) G\®µ¶©y @µ³j¶NRP ®ªsVV»R½Lò i F~LRiFyÈÁV©«s ¿ÁÖýÁLixmso ÇÁLjigjiLiµR¶¬s ª«sVV©«sVøLiµR¶V NRP©«sVg]¬s©«s xmsORPQLiÍÜ[, @ÉíÁÓ @µ³j¶NRP ®ªsVV»yò¬sõ ¼½Ljigji ¿ÁÖýÁLi¿Á[LiµR ¶VNRPV
Ëص³R¶Vù²R¶\®©s ª«so©yõ©«s¬s, @ÉíÁÓ ®ªsVV»yò¬sõ ©y zmsLi¿³ÁR ©«sV ©«sVLi²T¶ »R½gæij Li¿RÁVN]®©s[LiµR¶VNRPV ©y xqsª«sVø¼½¬s ¾»½ÖÁ¸R¶VÛÇÁ[qx sWò, BLiµR¶Vª«sVWÌÁLigS
úxmsNRPÉÓÁLi¿RÁV¿RÁV©yõ©«sV.

Date Signature of Subscriber / LTI

¾»½[µj¶ i ¿RÁLiµyµyLRiV xqsLi»R½NRPLi / ®ªs[ÖÁ ª«sVVúµR¶

Certified that the above Signature of Sri / Smt _____________________________________

S/O ____________________________________________ is signed in my presence.

\|ms©«s ¿Á[zqs©«s xqsLi»R½NRPLi / ®ªs[zqs©«s ËÜÈÁ©«s ú®ªs[ÖÁ ª«sVVúµR¶ $ / $ª«sV¼½ ____________________________________

(»R½Liú²T¶ }msLRiV) _____________________________________ ªyLjiµR¶¬s µ³R¶X-dsNRPLjiLi¿RÁ²R¶ª«sVLiVV©«sµj¶.

Station :
xqósÌÁª«sVV iM

Date
¾»½[µj¶ i

Office Seal Signature of the Gazetted Officer

NSLSùÌÁ¸R¶VLi ª«sVVúµR¶ µ³R¶X-dsNRPLjixqsVò©«sõ lgiÑÁÛÉÁ²`¶ @µ³¶j NSLji qx sLi»R½NRPLi

Name of the Officer

@µ³¶j NSLji }msLRiV

Designation
x¤¦Ü[µy
(Contd – 3)

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 :: 3 ::

1/-

Revenue Stamp
lLi®ªs©«sWù ríyLi£ms

STAMP RECEIPT
LRibdPµR¶V

Note : If the Amount exceeds 5,000/-, Revenue Stamp shall be affixed.

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Policy No. ___________

FyÌÁ{qs ®©sLiÊÁLRiV iM ___________

I ______________________ have received a sum of _______________ (Rupees

___________________________________________________________ Only) from Directorate of Insurance,
Andhra Pradesh, Hyderabad vide Cheque / D. D. / Online Payment No. ___________________ dated :
______________ towards sanction of Loan / Settlement of Claim against my Policies.

$ / $ª«sV¼½ ______________________ @©«sV ®©s[©«sV ÒÁ-s»R½ ÕdÁª«sW aSÅÁ \®²¶lLiNíPR lLi[ÈÁV, \|¤¦¦¦µR¶LSËصR¶V ªyLji ©«sVLi²T¶
________________ (LRiWFy¸R¶VÌÁV __________________________________________________________
ª«sWú»R½®ªs[V) ¾»½[µj¶ iM ______________________ ®©sLiÊÁLRiV ______________________ gRiÌÁ ¿ÁNRPVä / ²T¶. ²T¶. / A©±s \ÛÍÁ©±s }ms®ªsVLiÉÞ
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Signature
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I hereby certify that the above Signature of Sri / Smt ________________________________

is made in my presence.

$ / $ª«sV¼½ _____________________________________ ¿Á[zqs©«s \|ms xqsLi»R½NRPª«sVV ©y xqsª«sVORPQª«sVVÍÜ[ ¿Á[aSLRi¬s

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Station : Signature of Drawing and Disbursing

xqósÌÁª«sVV iM Officer with Seal
Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²R¶ @µ³j¶NSLji xqsLi»R½NRPª«sVV
NSLSùÌÁ¸R¶V ª«sVVúµR¶»][

Date : Name of Drawing and

¾»½[µj¶ iM Disbursing Officer :
Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²R¶
@µ³¶j NSLji }msLRiV iM

Designation :
x¤¦Ü[µy iM

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