apgli form

FORM NO.1-A ANNEXURE DIRECTORATE OF INSURANCE GOVERNMENT OF ANDHRA PRADESH:: HYDERABAD-1 POLICY NO. REGIONAL OFFICE PROPOSAL No. PROPOSAL FOR FURTHER INSURANCE (PLEASE ANSWER THE QUESTIONS FULLY AND DISTINCTLY) 1 Name in full (Block Letters): 2 Fathers Name in full : Designation : Date of Birth : 3 Are you Married : If married mention : i)No. of children Living and their present ages : ii) No. of childrens dead with ages & year of death : 24 Details of Service in State Government : a)Date of First Appointment: b)Present/Substantive post held if any: 24 If already insured with a) DIRECTORATE OF INSURANCE: 1) 2) 3) 24) a) to be filled after verifying policy documents b)Proposed monthly premium (deducted from the Salary Challan remitted) 24 a) Mention the date as on which the previous assurance was issued: b) Are you in good health? c)a) Has you health been effected since the : date of mentioned at (a) is so, give full particulars of the illness and treatment and treatment undergone alongwith pies of medical certificate if any. (b) Give particulars of leave applied for if any : on Medical Grounds, if none, state NIL' (c) Have there been any serious illness or death : among the members of your family since the date mentioned in answer to (a) above? Give details if any. Yes Rs. NIL Age: Female / Male : Address :-

Pay

Scale

POLICY NO. NOS.

/

MONTHLY PREMIUM

No.

No

No

(FOR FEMALES ONLY) 24 Have your periods been regular and painless and are they so now? 24 State the last date of your last menstruation: NIL 24 When was your last confinement? 24 Are you pregnant now? 24 Have you had any miscarriages? 24 Details of Nominations :a) Name of the Nominee/Nominees : b) Name of Nominees Father : c) Relationship of Nominee to the proponent : d) Present age of the Nominee/Nominees : e) Share/Shares : I do hereby declare that the above answers and particulars are correct and true that I have not withheld any information for an assurance on my life.

Date:

Signature of the person whose : Life is proposed to be assured.

CERTIFIED BY THE OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED I certify that the service particulars and other particulars stated above are correct and the proposer is now on leave at the time of declaration and th R in all Rs. from the pay of Sri s._ token No 15 to 20(20) vide dated ### and cheque No: ___ of A.P.A.O., T.G.P., Nellore ___ ___ Dated Signature: __ in Station: all Designation: Rs. ___ OFFICE SEAL ___ N.B. NOMINATION IS COMPULSORY. ___ ___ _ fro m the pa y of ___ ___ ___ ___ ___ _ vid e tok

APGLI FORM

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

V.Bhaktavathsalam Male Typist 10/28/1963 M.V.Ramana Kumar Male Sr.Asst. 4/11/1960 B.Vijaya Daniel Male Sr.Asst. 1/14/1973 G.Udaya Bhaskar Male Sr.Asst. 8/15/1969 G.Jaya Ramaiah Male Sr.Asst. 7/1/1961 SK.Kalesha Vali Male Jr.Asst. 7/14/1967 P.V.C.Madhusudhana PrasadMale Jr.Asst. 5/18/1975 N.Prabhakar Singh Male Jr.Asst. 8/12/1967 M.Srinivasulu Male Jr.Asst. 1/10/1966 G.Ramesh Babu Male Typist 7/1/1973 Ch.Ramanamma Female Typist 2/7/1971 A.Subba Rao Male Typist 8/15/1975 D.Subrahmanayam Male Jr.Steno 7/1/1967 O.Sarada Female A.E.E. N.V.L.P. Ramana Rao Male A.E.E. 6/10/1973 D.V.N. Siva Prakash Male A.E.E. G.Sivarama Murthy Male Jr.Tech.officer 8/14/1967 A.V.S. Prasad Male Tech.Asst. 10/15/1959 Ch.V.Subbamma Female Attender T.Manju Kumar Male Attender 8/19/1975 N. Rohini Prasad Male Attender 10/5/1968 Md. Nazeemunisa Begum Female Attender K.Ramaiah

Nio.of children Father's name V.Venkateswarlu M.V.Krishna Murthy B.Anandaiah G.Haanath Babu G.Ramachandraiah Late SK.Galishaid P.Subbarayudu N.Bala Bharath Singh M.V.Ramanaiah G.Hazarathaiah Ch.Siddi Raju A.Veeraiah D.Venkata Subba Raju O.Anjaneyulu N.B.C.Mohan Rao G.Radhakrishnaiah A.Subba Rao Late. T.Samel N Krishnaiah office S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. S.S.L.C. & S.B.Circle Office, Married 2 & S.B.Circle Office, Married 2 & S.B.Circle Office, Married 2 & S.B.Circle Office, Married 2 & S.B.Circle Office, Married 1 & S.B.Circle Office, Married 2 & S.B.Circle Office, Married 1 & S.B.Circle Office, Married 2 & S.B.Circle Office, Married 1 & S.B.Circle Office, Married 1 & S.B.Circle Office, Married 2 & S.B.Circle Office, Married 2 & S.B.Circle Office, Un-married --& S.B.Circle Office, Married 2 & S.B.Circle Office, Married 1 & S.B.Circle Office, Married & S.B.Circle Office, Married 1 & S.B.Circle Office, Married 2 & S.B.Circle Office, Married --& S.B.Circle Office, Married --& S.B.Circle Office, Married 2 & S.B.Circle Office, Married

ages

Dargamitta, Nellore.524003 13 Yrs 11 Yrs NIL Dargamitta, Nellore.524003 18 yrs 14 yrs NIL Dargamitta, Nellore.524003 4 Yrs 2 Yrs. NIL Dargamitta, Nellore.524003 11 yrs 10 yrs NIL Dargamitta, Nellore.524003 9 yrs. NIL Dargamitta, Nellore.524003 11 yrs 8 yrs NIL Dargamitta, Nellore.524003 3 Months NIL Dargamitta, Nellore.524003 NIL Dargamitta, Nellore.524003 5 yrs NIL Dargamitta, Nellore.524003 3 yrs NIL Dargamitta, Nellore.524003 11 yrs 8yrs NIL Dargamitta, Nellore.524003 8 yrs 5 yrs NIL Dargamitta, Nellore.524003 NIL Dargamitta, Nellore.524003 10 yrs. 8 yrs NIL Dargamitta, Nellore.524003 6 yrs NIL Dargamitta, Nellore.524003 NIL Dargamitta, Nellore.524003 9 yrs. NIL Dargamitta, Nellore.524003 21 yrs 19 yrs NIL Dargamitta, Nellore.524003 NIL Dargamitta, Nellore.524003 NIL Dargamitta, Nellore.524003 11 Yrs 9 Yrs NIL Dargamitta, Nellore.524003 NIL

Policy No. Present Typist 6845 5200-11715 493194 - A 75 Sr.Asst. 10845 6505-14665 438234 - ABC 125 Sr.Asst. 8170 6195-13945 475929 AB 75 Sr.Asst. 8385 6195-13945 475902-A 75 Sr.Asst. 8385 6195-13945 476731 - A 75 Jr.Asst. 6675 5200-11715 2001403 - A 75 Jr.Asst. 6675 5200-11715 2001306 - A 75 Jr.Asst. 7200 5200-11715 493548 - A 75 Jr.Asst. 7770 5200-11715 462104 -ABC 100 Typist 6350 5200-11715 2001919 - AB 75 Typist 6505 5200-11715 700418 - A 75 Typist 4950 4825-10845 2001304 -A 50 Jr.Steno 6505 5200-11715 2001918 - AB 75 A.E.E., 11715 10285-21835 2004962 - A 150 A.E.E. 9775 9285-19775 2002867 - A 150 A.E.E. 9520 9285-19775 New case 75 Jr.Tech.Officer 8600 5470-12325 471072 ABC 100 Tech.Asst. 8385 5200-11715 428243 - A 100 Attender 7015 4260-9520 448910 -AB 75 Attender 5075 3850-8815 2001305 - A 50 Attender 4825 3850-8815 2003136 -AB 50 Attender 4480 3850-8815 2003165 - A 100 New case

Total 250 450 350 350 350 250 250 250 350 250 250 200 250 450 350 350 350 350 250 200 200 150

proposed Assurance given dateDate of first appointment 175 10/14/1997 11/24/1994 325 12/27/2005 11/7/1981 275 0 3/31/1991 275 0 12/6/1990 275 0 11/30/1990 175 0 6/8/1995 175 0 9/29/1995 175 0 2/26/1993 250 0 12/2/1987 175 10/12/2000 7/29/1997 175 0 3/14/1996 150 0 3/28/1996 175 10/12/2000 3/11/1996 300 0 1/22/1996 200 0 11/3/1999 275 0 250 4/8/2003 11/29/1990 250 0 8/1/1979 175 0 150 0 7/11/1994 150 --5/20/1996 50

are you Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

good health C(A)(B)(C) No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No.

C(A)(B)(C) No No No No No No No No No No No No No No No No No No No No No No

7 No No No No No No No No No No No No No No No No No No No No No No -----------------------------------------------------------------------------------------

8 ---------------------------------------------

9 ---------------------------------------------

10 ---------------------------------------------

11 Name of the Nominee V.Chandra Kala M.Padma Prasuna B.Sirisha G.Meena Kumari K.Bharathi SK. Asia Parveen P.Manju Bhargavi N.Padma Gowri Bai M.Padmavathi G.Suvarna N.Srinivasulu A. Hymavathi D.Venkata Subba Raju M.Nagaraju D.V.S.K. Jyothsna G.Sandhya Rani A.Sujatha T.Sumalatha N Vijitha

K.Anjaneya Sarma C.Lakshmikantham A.Devadanam G.Subrahmanayam K. Sarveswaraiah Late. B.Ghouse Sreerama Murthy M. Balaji Singh M.Ramanaiah Late G.Raghavaiah N.Pullam Raju N.Ramanaiah D.Venkata Raju M.Subrahmanayam D.Veera Sekhar

Wife wife wife wife Wife wife wife Wife Wife wife Husband Wife Father Husband Wife

Late. V.Sreerama Sarma Wife S.Ramanaiah wife D.Mohan Rao I Balakrishnaiah Wife Wife

38 37 28 32 41 35 22 28 30 33 40 28 80 45 29

yrs. Yrs. Yrs. yrs. yrs. yrs yrs Yrs. Yrs. yrs. yrs Yrs. yrs yrs yrs

32 yrs. 44 yrs 22 yrs 32 Yrs.

Full Full Full Full Full Full Full Full Full Full Full Full Full Full Full Full Full Full Full Full Full Full

048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130, 048130,

Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005 Dt.31/12/2005

for for for for for for for for for for for for for for for for for for for for for for for

Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/Rs.391960/-

15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15

to to to to to to to to to to to to to to to to to to to to to to to

20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005 20(20) 12/31/2005

9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00 9317.00

From Sri C.Rajagopal Reddy, B.E., Superintending Engineer, S.S.L.C. & S.B.Circle, Nellore.

To The Asst.Director,. A.P.Govt. Life Insurance, Nellore.

Letter No. SE/SSLC& SBC/NLR/AB/S1/EC.4/ Dt. /01/2006 Sir Sub: A.P.G.L.I. - Revision of A.P.G.L.I. Subscriptions in R.P.S. 2005 Proposals for "Additional Insurance" - forwarded - Regarding. Ref: G.O. Ms. No..

Dt.

In terms of the Govt. Orders under reference cited, the monthly subscription to A.P.G.L.I of the following employees working in the S.S.L.C. & S.B.Circle Office, Nellore whose age is below 48 years is enhanced as per the limits given in the above G.O. and recovered from their pay bill for 12/2005. The proposals in the prescribed proforma obtained from them for " Additional Insurance " is hereby forwarded for issue of necessary bonds at an early date. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 S/Sri M.V.R.Kumar B.Vijaya Daniel G.Udaya Bhaskar G.Jaya Ramaiah SK.Kalesha Vali P.V.C.Madhusudhana Prasad N.Prabhakar Singh M.Srinivasulu V.Bhaktavathsalam G.Ramesh Babu Ch.Ramanamma A.Subba Rao D.Subrahmanayam O.Sarada N.V.L.P. Ramana Rao D.V.N. Siva Prakash G.Sivarama Murthy A.V.S. Prasad Ch.V.Subbamma T.Manju Kumar N. Rohini Prasad Md. Nazeemunisa Begum K.Ramaiah ( first proposal form) Sr.Asst. Sr.Asst. Sr.Asst. Sr.Asst. Jr.Asst. Jr.Asst. Jr.Asst. Jr.Asst. Typist Typist Typist Typist Jr.Steno A.E.E. A.E.E. A.E.E. D.M.Gr.III Tracer Attender Attender Attender Attender Attender Yours faithfully, C.Rajagopal Reddy, Superintending Engineer, SSLC & SB.Circle, Nellore.

Encl:- 23 Nos. proposals in original as received. //t,c,f.b.o//

Superintedent

up

/01/2006

Engineer, e, Nellore.

FORM NO.1-A ANNEXURE DIRECTORATE OF INSURANCE GOVERNMENT OF ANDHRA PRADESH:: HYDERABAD-1 POLICY NO. REGIONAL OFFICE PROPOSAL No. PROPOSAL FOR FURTHER INSURANCE (PLEASE ANSWER THE QUESTIONS FULLY AND DISTINCTLY) 1 Name in full (Block Letters): 2 Fathers Name in full : Designation : Date of Birth : 3 Are you Married : If married mention : i)No. of children Living and their present ages : ii) No. of childrens dead with ages & year of death : 4 Details of Service in State Government : a)Date of First Appointment: b)Present/Substantive post held if any: 5 If already insured with a) DIRECTORATE OF INSURANCE: 1) 2) 3) 4) 5/20/1996 Pay 4825 POLICY NO. / NOS. 2003136 -AB 2 No. NIL Age: 11 Yrs 9 Yrs N. Rohini Prasad N Krishnaiah Attender 10/5/1968 Yes Female / Male : Male

Address :S.S.L.C. & S.B.Circle Office, Dargamitta, Nellore.524003

Scale 3850-8815 MONTHLY PREMIUM 50.00

a) to be filled after verifying policy documents b)Proposed monthly premium (deducted from the Salary Challan remitted) 6 a) Mention the date as on which the previous assurance was issued: b) Are you in good health? c)(a) Has you health been effected since the : date of mentioned at (a) is so, give full particulars of the illness and treatment and treatment undergone alongwith copies of medical certificate if any. (b) Give particulars of leave applied for if any : on Medical Grounds, if none, state 'NIL' (c) Have there been any serious illness or death : among the members of your family since

Rs. 150.00

---

Yes

No.

No

No

the date mentioned in answer to (a) above? Give details if any. (FOR FEMALES ONLY) 7 Have your periods been regular and painless and are they so now? 8 State the last date of your last menstruation: NIL 9 When was your last confinement? 10 Are you pregnant now? 11 Have you had any miscarriages? 12 Details of Nominations: a) Name of the Nominee/Nominees : b) Name of Nominees Father : c) Relationship of Nominee to the proponent : d) Present age of the Nominee/Nominees : e) Share/Shares :

N Vijitha I Balakrishnaiah Wife 32 Yrs. Full

I do hereby declare that the above answers and particulars are correct and true that I have not withheld any information for an assurance on my life.

Date:


CERTIFIED BY THE OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED I certify that the service particulars and other particulars stated above are correct and the proposer is now on leave at the time of declaration and the proponents signature has been a fixed in my presence. The first premium for further insurance is recovered at

R 150.00 in all Rs. 9317.00 from the pay of Sri N. Rohini Prasad s._ token No 15 to 20(20) vide dated ### and cheque No: 048130, Dt.31/12/2005 for Rs.391960/___ of A.P.A.O., T.G.P., Nellore ___ ___ Station : Signature: __ in all Date : Designation: Rs. ___ ___ OFFICE SEAL ___ ___ _ N.B. NOMINATION IS COMPULSORY. fro m the pa y of ___ ___ ___

FORM NO.1-A ANNEXURE DIRECTORATE OF INSURANCE GOVERNMENT OF ANDHRA PRADESH:: HYDERABAD-1 POLICY NO. REGIONAL OFFICE PROPOSAL No. PROPOSAL FOR FURTHER INSURANCE (PLEASE ANSWER THE QUESTIONS FULLY AND DISTINCTLY) 1 Name in full (Block Letters): 2 Fathers Name in full : Designation : Date of Birth : 3 Are you Married : If married mention : i)No. of children Living and their present ages : ii) No. of childrens dead with ages & year of death : 4 Details of Service in State Government : a)Date of First Appointment: b)Present/Substantive post held if any: 5 If already insured with a) DIRECTORATE OF INSURANCE: 1) 2) 3) 4) a) to be filled after verifying policy documents b)Proposed monthly premium (deducted from the Salary Challan remitted) 6 a) Mention the date as on which the previous assurance was issued: b) Are you in good health? c)(a) Has you health been effected since the : date of mentioned at (a) is so, give full particulars of the illness and treatment and treatment undergone alongwith copies of medical certificate if any. (b) Give particulars of leave applied for if any : on Medical Grounds, if none, state 'NIL' (c) Have there been any serious illness or death : among the members of your family since 11/4/2003 Pay 9285 POLICY NO. NOS. / 2 No. NIL Age: 5 Yrs 2 Yrs M.Muralikrishna M. Srinivasulu Asst Execuitve Engineer 7/1/1976 Yes Female / Male : Male

Address :Executive Engineer, S.S.L.C. & S.B. Division No.2, Nellore.

Scale 9285-20550 MONTHLY PREMIUM 200.00

Rs. 150.00

---

Yes

No.

No

No

the date mentioned in answer to (a) above? Give details if any. (FOR FEMALES ONLY) 7 Have your periods been regular and painless and are they so now? 8 State the last date of your last menstruation: NIL 9 When was your last confinement? 10 Are you pregnant now? 11 Have you had any miscarriages? 12 Details of Nominations: a) Name of the Nominee/Nominees : b) Name of Nominees Father : c) Relationship of Nominee to the proponent : d) Present age of the Nominee/Nominees : e) Share/Shares :

M. Jyothsna Ch V Sesha Reddy Wife 27 Yrs. Full

I do hereby declare that the above answers and particulars are correct and true that I have not withheld any information for an assurance on my life.

Date:


CERTIFIED BY THE OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED I certify that the service particulars and other particulars stated above are correct and the proposer is now on leave at the time of declaration and the proponents signature has been a fixed in my presence. The first premium for further insurance is recovered at R 150.00 in all Rs. from the pay of Sri M.Muralikrishna s._ token No vide dated and cheque No: ___ of A.P.A.O., T.G.P., Nellore ___ ___ Station : Signature: __ in all Date : Designation: Rs. ___ ___ OFFICE SEAL ___ ___ _ N.B. NOMINATION IS COMPULSORY. fro m the pa y of ___ ___ ___

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