Download Application Form For Further Insurance Proposal

; .; --;J o.1-o FORM NO. 1-A .;.o(S o ANNEXURE .. f i lJOJS OS O $dM. DIRECTORATE OF INSURANCE .o (S tf .S.S., .tS O . tS-1. GOVERNMENT OF ANDHRA PRADESH : HYDERABAD-1 & d ;J o. & obM O $dMo POLICY NO. ____________________ REGIONAL OFFICE <& tS ; ;J o ......................... Proposal No. _______________ .tS ; .. <& tS ; PROPOSAL FOR FURTHER INSURANCE (tS M fd. a![ ;, . o[ ; .( ; o 9.Sol? ) PLEASE ANSWER THE QUESTIONS FULLY AND DISTINCTLY) 1. (o) a! ! OS : (.l? ..S OS .d. ) ./ OS lS Name in full (Block Letters) Female/Male 2. (.) .o l? a!! OS : .OS; . Father's Name in Full: Address: ( ) t : Designation (l? ) .?; .c: Date of Birth 2. (o) . OS .. .. : Are you Married (.) .. ... , .. O d . d ol? : If married, Mention _____________________ (i) ..o..S; d d oi$, . a !. .M d : No. of Childrens Living and their present ages. (ii) . OS M? o.; d d oi$, . a .M , . OS M? o.; o.. OS . No. of Childrens dead with ages & Year of death 3. O . .S S. S .. OS . d : Details of Service in State Government (o) .J tS .? )M. S c Date of First Appointment ( ) !. / .OS 8t $[S o EtJ; Present/Substantive post held if any 8; . ; . Pay ! /d Scale 4. 9c. OS .. f i lJ OJ S OS O $dM o. If already insured with DIRECTORATE OF INSURANCE .. 8; & d ;J o/;J o.OS POLICY NO/NOS. ;J d a M o MONTHLY PREMIUM (o) (& d d (S J. S ao .; O S. )o& .) (to be filled after verifying policy documents) ( ) <& co.; ;J d a M o (.. . ; ol? o.o/ J . o.; ; ) Proposed monthly premium (deducted from the salary/Challan remitted) 5. (o) OS S .. . .O ; 6; ! O;/; .l? Mention the date as on which the previous assurance was issued: ( ) .O [S $o .[S [ 8ot . Are you in good health? ( ) (o) .of o. ! O;/; 6 ;ol? .O [S $o tJ ..<;t . .O , ..? S .. , &.otS ; . ? .a! .. O d; d ol? , E.J ; .J tS $ (S J. d 8;. O . .? d; .. OS ol? . Has you health been effected since the date of mentioned at (a) is so, give full particulars of the illness and treatment undergone alongwith copies of medical certificate if any. (l? ) .J tS $ OS M d. EtJ ; d.S tS OS .! 8; O ,. .. O d d ol? ..? c Ec .; O , ,,E. tS .) .d ol? Give particulars of leave applied or if any on Medical Grounds, if none, state "Nil' (9) ; ! O;/; (o) .of ) ? . ( ; o 9.;; 6 ; ol? o. .S $d. o. OJ ; b . .J ; S [S OJ ; O .S . OS M? o lS o .aoot .EtJ ; .S ; O .. O d d ol? 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 .d. . . ) (FOR FEMALES ONLY) 6. OS S . d S . .tS lo[ (S .ol 8; M 9 ylS .l [ 8; M Have your periods been regular and painless and are they so now? 7. S lS & a OS S . o .6) .d ol? State the last date of your last menstruation 8. (o) .. a & a[ [S OS Jo (S ao.; 6) .d ol? . When was your last confinement? ( ) !. o .OS [S OS J. . Are you Pregnent now? 9.. OS o ylJ; [S OS J & . d .a[ M Have you had any miscarriages? 10. ; .; ; .. O d : Details of Nominations: (o) ; .//; ./d ! OS /! OS : Name of the Nominee/Nominees () ; . / .o l? ! OS : Name of the Nominee' Father: ( ) <& tS .) ? ; . /. [S d o.o(S o Relationship of Nominee to the proponent (l? ); . //; ./d !. . M /. M d : Present age of the Nominee/Nominees (9) . ./. .d : Share/Shares ; ! O;/; . ( ; d , .. O d OJ ; . ), )..J ; . )M ; .. ). .!o ; ; o. . o.? . O ) t . .S o tS )M 9otS . d. [ S .? !; ; . I do hereby declare that the above answers and particulars are correct and true that I have now withheld any information for an assurance on my life. : . .. M tS d.; . $ ? ! o. S . DATE: ____________ Signature of the person whose Life is proposed to be assured <& tS ; E .wa . .S o. o. S o M lS . O ot a (S J. S OS M .w CERTIFIED BY THE OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED ; ! O;/; S .. O d , .c. OS .. O d aMJ ; . ), )..J ; . )M , S .; ! . M o. <& tS .lS d.S lS )M .M ; ; . .S o. o. S o ; lS )M ; ; (S J. OS !; ; . .tS ; .. ). .!o .J tS .? M o; OS . ........................ ; y; OS ............... ......... .J !) .......................... . ; o ; ol? ................ .c [S d ;J o ........................... .S ; . d M lS . O oc. 9otS o.owo. t ) J ./ ;J o.OS ................. c.................... I certify that the service particulars and other particulars stated above are correct and the proposer is not on leave at the time of declaration and the proponent's signature has been a fixed in my presence. The first premium for further insurance is recovered at Rs. _____________ in all Rs. ________ from the pay of _____________ Vide token No. ____________ Dated ________________ and Cheque No. ___________ Dated ___________ .do: o. S o: Station : _______________ Signature : _________________ c t : DATED: _____________ Designation : ____________ O $dM . tS OFFICE SEAL [S . ) S : ; .; ; .) a[ 8ol .. N.B.:- NOMINATION IS COMPULSORY.