APPLICATION FOR POLICY

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Form 1

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DIRECTORATE OF INSURANCE

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GOVERNMENT OF ANDHRA PRADESH

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HYDERABAD

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DISTRICT INSURANCE OFFICE ___________

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PROPOSAL FORM

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All Columns shall be filled in capitals only

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Policy No. ___________

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1. Name }msLRiV
Surname BLi }msLRiV

Proposal Form No. ___________

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Full Name

3.

Fathers Name

5.

Employee Office Address

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2.

Male /

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Female /

4. Designation x[y

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7.

Date of First Appointment

8.

Marital Status

6.

Date of Birth xmso s [j

(As per Service Register)
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Married

Unmarried

If married, No. of Children and their ages

9.

Sex

Widow

Divorced

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10.

Basic Pay and Pay Scale

11.

DETAILS OF NOMINATION

S. No.

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Name of Nominee Name of Nominees Father

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Are you in Good Health

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Age

Relationship of Nominee

Share

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Yes / @sosV

No /

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(Contd 2)

:: 2 ::

13.

Have you in the preceeding (3) years been absent on Leave on

Medical Grounds for more than (10) days at a
time ? If Yes, give details

Yes / @sosV

No /

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14. 1. Have you ever suffered from any of the following Diseases :C NTPLij }msL]s yRV[ [s][\sy -dsVLRiV FsxmsV\y Rmx syLS ?

2.

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Heart Ailment

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Yes / @sosV

No /

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Kidney

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Yes / @sosV

No /

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Cancer

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Yes / @sosV

No /

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Lungs

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Yes / @sosV

No /

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

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15.

Are you a physically challenged person. If so, enclose Certificate issued

Yes / @sosV

by a Competent Authority

No /

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16.

If already insured

Policy No.

Total Monthly Premium

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17.

Proposed Monthly Premium

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18.

Month and Year of Recovery

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Mobile No.

20.

Email Address

22.

Employee ID No.

23.

Major Head

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21.

Aadhar Card No.

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Try. D. D. O. Code

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Declaration by the Proponent

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(Contd 3)

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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.

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Date

Signature

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CERTIFIED BY OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED

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LRiW. ___________ (Bj sLRiZNP[ Rgij Lixmso [zqss sVLjiRVV xmsxqsVR {ms-sVRVLi NRPVxmsoN]s) ___________ s sVLjiRVV ___________
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I certify that the service particulars stated above are correct and the Proponents 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 __________________

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Station

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Date
For OFFFICE USE
O.R. (

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

x[y

Designation

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Office Seal

Supdt.

DIO

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