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    Bhavithav
    1. This document appears to be an application for an insurance policy from the Directorate of Insurance in Andhra Pradesh, India. 2. It requests personal information such as name, age, employment details, health history, and nomination of beneficiaries. 3. The applicant must declare that all information provided is true and promise that any false statements will result in forfeiture of premiums paid under the policy.

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    © All Rights Reserved
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    Female/: Full Name

    Uploaded by

    Bhavithav
    13 views3 pages
    1. This document appears to be an application for an insurance policy from the Directorate of Insurance in Andhra Pradesh, India. 2. It requests personal information such as name, age, employment details, health history, and nomination of beneficiaries. 3. The applicant must declare that all information provided is true and promise that any false statements will result in forfeiture of premiums paid under the policy.

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    1. This document appears to be an application for an insurance policy from the Directorate of Insurance in Andhra Pradesh, India. 2. It requests personal information such as name, age, employment details, health history, and nomination of beneficiaries. 3. The applicant must declare that all information provided is true and promise that any false statements will result in forfeiture of premiums paid under the policy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    13 views3 pages

    Female/: Full Name

    Uploaded by

    Bhavithav
    1. This document appears to be an application for an insurance policy from the Directorate of Insurance in Andhra Pradesh, India. 2. It requests personal information such as name, age, employment details, health history, and nomination of beneficiaries. 3. The applicant must declare that all information provided is true and promise that any false statements will result in forfeiture of premiums paid under the policy.

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    GCP-183-14-8-2013-1,00,000.

    APPLICATION FOR POLICY


    AT OF.
    nHRA
    NOE
    AP

    Form-11
    o 1

    DIRECTORATE OF INSURANCE

    GOVERNMENT OF ANDHRA PRADESH

    HYDERABAD

    DISTRICT INSURANCE OFFICE

    PROPOSAL FORM

    All Columns shall befillad in capitats only


    Proposal Fom No..
    Policy No..
    . Name se
    Surname aod be 2. Sex Male/Hebdo
    Full Name
    Female/
    4. Designation
    3. Father's Name so o
    CL
    5. Employee Office Adciress s5'sd s r g o a Ddbrs
    6. Date of Birth bgs da D DMM YYY
    (As per Service Register)

    PN
    Appointment s s Dainá aa
    7. Date of First D DM MYYYY

    8. Marital Status
    LMarried Unmarried Widow Divorced

    9. If married, No. of Children and their ages sooo (do. 6)

    10. Basic Pay and Pay Scale sae 3s3án a8eda Sé3sao ozes

    Dso-w
    1. DETAILS OF NOMINATION »b Sharee
    Name of Nominee Name of Nominee's Father Age Relationship of Nominee
    S. No.

    12. Are you in Good Health pso u'ngo a () TickYes./ No/ sr


    (Contd 2)
    2

    13. Have you in the preceeding (3) years been absent on Leave on
    Yes /oá No ra
    Medical Grounds for more than (10) days ata
    time ?If Yes, glve details

    14. 1. Have you ever suffered from any of the following Diseases

    . Heart Ailment oaog Yes/s No/


    D. Kidney adodo Yes/ No/
    . Cancer Yes/ No/
    . Lungs
    Yes/h No rs
    2. If Yes, give details of Disease, duration and Treatment received

    Joo
    15. Are you a physically challenged person. If so, enclose Certificate issued
    by a Competent Authority
    Yes/ io No

    16. If alreadyInsured Policy No. Total Monthly Premium


    b Sdas)s*
    17. Proposed Monthly Premium d o d s Boso Aaabo

    18. Month and Year of Recovery go #6hs 3o soao dossso


    19. Mobile No. p 6 3o.

    20. Email Address oewd Débr 21. Aadhar Card No. up5 » 3o.

    22. Employee ID No. adgn bgoo 3o.

    2. Major Head o* # Try. D. D. 0. Code Ba 8. 3. . sif8

    Declaration by the Proponent

    eododssedatose sdseio Dosiocsdsao dar 6vago bosdsDa» dáo aods savoun 853osbdba-

    (Contd-3)
    3

    I do hereby declare that the foregoing detalls and Answers have


    understanding the questions, the same are true, full been glven by me after
    and complete whether written in my own hand writing or fully
    every parücular and that I have not withheld or
    concealed any clrcumstances wlth regard to which not in
    been required from me. I information
    agree that the foregolng statements and declaratlon shall be the basis of has
    contract for an Insurance and that if It shall hereafter appear that I have willfully made any untrue the proposed
    statement or
    have fraudulently concealed any circumstances which I
    have been pald under the said contract shall be forfeited ought to have made known then all the Premla which shall
    and the contract rendered absolutely null and vold."

    Date
    Signature

    CERTIFIED BY OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED

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

    Station

    Date

    For OFFFICEUSE Signature


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

    Designation

    office Seal

    Supdt. DIO
    Please visit our Website : www.apalil.ap.govin for further Information and guldelines

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