01/2014

CLAIM FORM
ZNý L VVª± V µ³R LR ÆØxq Vò
Form No. 12
©« ª« VW©y ®© L . 12
Inward No.
@L »R LæS• V ®© L .

APGLI Office Use Only

NSLSùÌ ¸R Vxm o Dxm ¹¸ WgSLóR L
DIRECTORATE OF INSURANCE
\®² lL NíR lL ÉÞ A£mn B©« W=lL ©± =
GOVERNMENT OF ANDHRA PRADESH
AL úµ³R úxm ®µ [a` úxm Ë³Ï V»R *ª« VV, AL úµ³R úxm ®µ a[`
HYDERABAD, Andhra Pradesh
\|¤ µR LSËص`
Refund Form No. 1 District Insurance Office :
Lj mxn L ²` FnyLR L ®© L . 1 Ñ ÍýØ Õd ª« W NSLSùÌ ¸R VL M
APPLICATION FOR REFUND OF AMOUNT FROM THE DIRECTORATE OF INSURANCE, HYDERABAD
(To be filled by the Subscriber)
Õd ª« W aSÅ \®² lL NíR lL È[ V NSLSùÌ ¸R VL , \|¤ úµyËصR V ©« VL ²T ®ª VV»R òL ªyxm xq VN][LR V»R V©« õÉíÓ µR LR ÆØxq Vò
(µk ¬ ¬ ¿R L µyµyLR V xm pLj ò ¿ [¸R WÖ )
Policy No.
FyÌ {q ®© L .

1. Name of the Subscriber ¿R L µyµyLR V¬ }m LR V

2. Father’s Name »R L ú²T }m LR V 3. Designation x¤ Ü[µy

4. Name of the Office and the District where the Subscriber was last in Service
¿R L µyµyLR V xq Lk *xq V À ª« Lj L][Ç ÙÌ ÍÜ[ xm ¬ ¿ [zq ©« NSLSùÌ ¸R Vª« VV }m LR V, Ñ ÍýØ }m LR V
5. Date of Maturity
D D M M Y Y Y Y
6. Date of Birth D D M M Y Y Y Y
FyÌ {q xm Lj ß ¼ ¾» [µj xm oÉíÓ ©« ¾» [µj
7. a) Date of Retirement
D D M M Y Y Y Y
F ) xm µR • • LR ª« Vß ¾» [µj

Nature of Retirement ( ) xm µR Superannuation Voluntary Compulsory

• • LR ª« Vß xq *˳ت« L xq Wxm LS©« Vù¹¸ V[ xt ©± xq *¿R èéL µR ¬ LR ÷L µ³R
b) Month of last deduction of Premium
Õ ) ú{m • V¸R VL ®ª VV»yò¬ õ ª« xq WÌ V ¿ [zq ©« À ª« Lj ¾ ®© Ì
8. Name of the Bank where payment is desired
¿ Öý L xm o N][LR V¿R V©« õ ËØùL N` }m LR V

Branch Name úËØL À }m LR V

IFS CODE H F £mn ¸R V£q N][²`

Bank Account No. ËØùL NR V ÆØ»y ®© L Ê LR V

(Contd – 2)
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 :: 2 ::

9. Employee I. D. No. Dµ][ùgj H²T ®© L Ê LR V

10. Mobile No. ®ª VV\ÛË ÍÞ ®© L Ê LR V

11. Aadhar Card No. Aµ³yL` NSL`ï ®© L Ê LR V

12. Office in which the subscriber has worked during the last (5) years
¿R L µyµyLR V À ª« Lj (5) GÎýÏ § xm ¬ ¿ [zq ©« NSLSùÌ ¸R VL }m LR V
13. Full Address of the Applicant with Pin Code
µR LR ÆØxq Vò µyLR V xm pLj ò À LR V©yª« W zm ©± N][²` »][ xq ¥

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
F) G. zm . Ñ . F ÍÞ. H. ©« VL ²T Ê VVß L F~L µj ª« o©yõ©« V. C ®ª VV»yò¬ NT gS©« V,
¿ Öý L ¿R ª« Ì zq ª« o©« õµj . C ®ª VV»yò¬ õ ª« ²ïU »][ xq ¥ ©y FyÌ {q ®ª VV»R Lò ©« VL ²T ª« xq WÌ V ¿ [xq VN]©« ª« ¿R Vè©« V

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.
Õ ) G\®µ ©y @µ³j NR ®ª VV»R Lò F~LR FyÈ V©« ¿ Öý L xm o Ç Lj gj L µR ¬ ª« VV©« VøL µR V NR ©« Vg]¬ ©« xm OR L ÍÜ[, @ÉíÓ @µ³j NR ®ª VV»yò¬ õ ¼ Lj gj ¿ Öý L ¿ [L µR VNR V
Ëص³R Vù²R \®© ª« o©yõ©« ¬ , @ÉíÓ ®ª VV»yò¬ õ ©y zm L ¿³R ©« V ©« VL ²T »R gæj L ¿R VN]®© [L µR VNR V ©y xq ª« Vø¼ ¬ ¾» Ö ¸R VÛÇ [xq Wò, BL µR Vª« VWÌ L gS úxm
NR ÉÓ L ¿R V¿R V©yõ©« V.

Date Signature of Subscriber / LTI

¾» [µj ¿R L µyµyLR V xq L »R NR L / ®ª [Ö ª« VVúµR

Certified that the above Signature of Sri / Smt

S/O is signed in my presence.

\|m ©« ¿ [zq ©« xq L »R NR L / ®ª [zq ©« ËÜÈ ©« ú®ª [Ö ª« VVúµR $ / $ª« V¼

(»R L ú²T }m LR V) ªyLj µR ¬ µ³R X•d NR Lj L ¿R ²R ª« VL VV©« µj .

Station :
xqó Ì ª« VV M
Date
¾» [µj

Office Seal Signature of the Gazetted Officer

NSLSùÌ ¸R VL ª« VVúµR µ³R X•d NR Lj xq Vò©« õ lg Ñ ÛÉ ²` @µ³j NSLj qx L »R NR L

Name of the Officer

@µ³j NSLj }m LR V

Designation
x¤ Ü[µy
(Contd – 3)

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 :: 3 ::

1/-

Revenue Stamp
lL ®ª ©« Wù ríyL £m
STAMP RECEIPT
LR bd µR V

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

gR ª« V¬ NR M \|m NR L 5,000/c Ì NR V • VL À ©« Èý L VV¾» [ ríyL xm o @¼ NT L ¿yÖ

Policy No.
FyÌ {q ®© L Ê LR V M

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« V¼ @©« V ®© [©« V Ò • »R Õd ª« W aSÅ ®²\ lL NíR lL [È V, |\¤ µR LSËصR V ªyLj ©« VL ²T

(LR WFy¸R VÌ V
ª« Wú»R ®ª [V) ¾» [µj M ®© L Ê LR V gR Ì Â¿ NR Vä / ²T . ²T . / A©± \ÛÍ ©± }m ®ª VL ÉÞ
µy*LS @L µR VN]©« õÈý V BL µR Vª« VWÌ ª« VVgS LR bd µR V @L µR ¿ [xq Vò©yõ©« V.

Signature
xq L »R NR ª« VV

I hereby certify that the above Signature of Sri / Smt

is made in my presence.

$ / $ª« V¼ ¿ [zq ©« |\m xq L »R NR ª« VV ©y xq ª« VOR ª« VVÍÜ[ ¿ [aSLR ¬

µ³R X•d NR Lj L ¿R V¿R V©yõ©« V.

Station : Signature of Drawing and Disbursing

xqó Ì ª« VV M Officer with Seal
Ax¤ LR ß ª« VLj ¸R VV Ê ÉØ*²R @µ³j NSLj xq L »R NR ª« VV
NSLSùÌ ¸R V ª« VVúµR »][

Date : Name of Drawing and

¾» [µj M Disbursing Officer :
Ax¤ LR ß ª« VLj ¸R VV Ê ÉØ*²R
@µ³j NSLj }m LR V M

Designation :
x¤ Ü[µy M

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