APGLI Refund Form (Other Than Death Claim)

¯èþÐè þ¯é þ¯é ¯ð þ. þ. 12 FORM No. 12

ÁÐèþÔéQ yðþÆð ÿMæÿMæ ütütÆóÆ ÿó r, BÉ«æ þÉç  ³§ó   þÔ ý,  ò ß   §æþÆé»ê§æ þ.   DIRECTORATE OF INSURANCE :: ANDHRA PRADESH :: HYDERABAD HYDER ABAD

ÁÐèþÔéQ É´ë¡Äè ÿÿ yìþç ³Åsî    ü yð þþÆðÆÿMæ ðÿMæ ütütÆæÆÿ æÿ MéÆéÅËÄè ÿÐè ÿÐè þ  þ  ____________________________________________ OFFICE OF REGIONAL DEPUTY DIRECTOR OF INSURANCE _________________________

¯èþÐè   þ¯é ¯ðþ. 1 FORM NO.1

ÁÐèþ  þ ÔéQ yðþÆð ÿMæÿMæ ütütÆóÆ óÿr ÿr MéÆéÅËÄèÿ, ò ß  ɧé»ê§æ þþ ¯èþyìþ Ððþè þ¢þ¢ Ðéç³ç   ÜMøÆæÿèþ¯èþ²sìüt «æþÆæÿRêçÜ¢ (©°° ^èþ§é§éÆæ ÿÿ  ç³Ç¢   ^ó þÄè þÄèÿÍ) APPLICATION APPLICATION FOR REFUND OF AMOUNT FROM THE DIRECTORATE DIRECTORATE OF INSURANCE :: HYDERABAD (To (To be filled by the t he subscriber)

1.

2.

3.

^èþ§é þ §é§é §éÆæÆæÿ õ ³Ææÿ, Aèþ° þ ° èþÉyì þ Éyì þõþ õ³ Ææÿ, çßø§é

:

Subscriber's name and name of his father and designation

:

^è þ§é§éÆæ ÿ ç ÜÈÓç Ü _ÐèþÇ þ Ç ÆøkËÌø ç ³°^ó    þíþ íÜ¯è   þ MéÆéÅËÄèÿÐè  ÿÐèþ õ³Ææ ÿ, ÿ, hÌêÏ ³Ææ  õ   ÿÿ 

:

Name of the office and the District wher wheree the the subs subscr crib iber er was was las lastt in in ser servi vice ce

:

^þ§é§éÆæ è   ÿ° ´ëËï Ü,  Ìôý§é ´ëËï ÜË   ¯ðþºÆæÿ, ÿ , Ðésì ü Ðésìü Ðð þé¢ þé¢Ë Ë Ìôý§é  ý§é Aèþ° É´ëÑyð þrç þrç·yæ    þ  Ü¿æ  ç   ýÅyð þ¯è¯þ þè rÏÆÿô Æÿôþ, Çhç Ùt ÆæÆÿ æÿ ¯ðþ. Number of policy or policies and their respective amounts or register number of the subscriber if he was a member of theProvident Fund.

4.

´ëËïÜ  Ðð þ^è þ ^è þÅÇsî þÅÇsîü ô þ¨ þ¨

:

Date of Maturity of the Policy

:

5.

6.

G)

çÜÈÓçÜ   ÜÐè  ç    þç þç³¢ÐðÐþð ¯è¯ èþ ôþ¨: þ ¨:

a)

Date Date of term termin inaatio tion of serv servic icee

¼)

Éï³ÑÄè     ÿ  ÿ Ððþ颰² °² ÐèþÜË ç    ^óþܯè í     þ _ÐèþÇ  þÇ ¯ð þË  þË 

b)

Mont Month h of last last dedu deduct ctio ion n of prem premiu ium m

D Ððþé°² ¢°² 55/58 çÜÐè þèþè þÞÆéË  þÞÆéË  ÐèþÄè  þÄè ÿçÿç ÜÞ   ç³Ç¢ MéNyé¯óþ  MóüÏÆÿÐè ÆÿÐèþ  ^óþçÜ¢¯é²Æé? Is the amount being claimed before the completion of age 55/58

7.

D Ðþè ð    þ¢þ¢ ^ðþÍÏ  þÍÏç³ MøÆæÿèþ¯èþ²sì ütüt BÉ«æþÉç ³§ó  þÔý Éç ³¿æ  ýè þÓþÓ ÉsðüfÈ õ ³Ææ  ÿÿ  Ìô ý§é ý§é õÜtssü   »êÅM ü  B ·  ß  ò   §æ§ þÆé»ê§ æþÆé»ê§ þ  Ìôý§é  ý§é  õÜt ss ü  »êÅM ü  B· Cyì þÄè þÄè ÿ ÿ É»ê_  õ³Ææ   ÿÿ

:

Name of the Andhra Pradesh Government Treasury or the Branch of the State bank of Hyderabad or State Bank of India from which payment is desired.

8.

^èþ§é§éÆæ   ÿ _Ðè þÇ þÇ (5) HâèýÏ ³°^ó  ç   þí Ü¯è   þ MéÆéÅËÄèÿ õ³Ææÿ: Office in which the subscriber has worked during the last (5) years

9.

§æþÆæ ÿRêçÜ¢§éÆæ §éÆæ ÿÿ ç³Ç¢ _Ææÿ¯éÐè  ÿ¯éÐè þ þ Full address of the Applicant

10 10)) G)

Ææÿ. . ....... .......... ...... ...... ...... ....... ....... ...... ...... ...... ..... .. H.í³.h. .h.GÌ GÌý.I. .I. ¯èþyì yìþ º}ý º}ý ´÷¨Ðæ ´÷¨Ðæþ¯é²Æ ¯é²Æææÿ. D Ðð þé¢ þ颰Mìü Vé¯èþ, Ææÿ. .............................. ^ðþÍÏ ^èþÐèþËíÜ Ðæþ¯è þ ¯èþ²¨. D Ððþ颰²  Ðèþyî þyîþzø ø çÜà ¯é ´ëËï Ü  Ððþè þ èþ¢ ¯è þyì þyì þ Ðèþçþ  çÜË   ^óþçþ  çÜMö^è   þa¯è  þa¯è þ. þ. I have obtained A.P.G.L.I. A.P.G.L.I. Loan of Rs. ____________________ , out of which I have to pay Rs. ______________________ which may be recovered alongwith interest from my policy amount.

¼)

H§ðþ¯é ¯é A¬Mæ ü Ðð þè þèþ¢ ´÷Ææÿ´ër¯è  ÿ´ër¯èþ ^ðþÍÏç³  ç   fÇW§æ þ° þ° Ðèþ¯è  þ¯è þÃ§æ þÃ§æ þþ Mæ ü¯èü¯è þVö°¯è þVö°¯èþ ç³æ þÌø, þÌø, Asì ütüt A¬Mæü  Ðð þé¢ þ颰² °² ÇW ^ð þÍÏ þÍÏ^ó ^óþ§æ  þ§æ þN  þN  »ê«æþÅyæ þ Åyæþ¯ðþ ¯ðþ þ Ðæþ¯é²¯è  þ¯é²¯è þ°, þ°, Asì ütüt Ððþé¢  þ颰² °² ÐéÆÿ§éËÌø ¯é  í ·^è   þ¯èþ ¯è þþ ¯è þyì þyìþ  èþWY þ WY^è ^èþMö¯ó þ Mö¯óþ§æ þ §æ þN þN ¯é  çÜÐè  þÃ° þ Ã° ñþÍÄè þ ÍÄèÿgô ÿ gô ýçýÜç ¢ C§æ þÐè þÐèþËVé þ ËVé Éç³Mæüsìü^èþ^èþ¯é²¯èþ. I do hereby declare that if in future it is found that any excess payment was made to me in advertantly, advertantly, I shall be held responsible to repay such excess amount and given my consent for deduction of the same from my pension instalments.

ô þ¨ þ¨ :

_____________ Date: _____________

^èþ§é§éÆæÿÿ  çÜèþMæü  Signature of Subscriber

 ò³  ¯è¯ èþ ^óþíþ  íÜ¯è  þ çÜè     þMæ ü/Ðó ü/Ðó þíþ íÜ¯è  þ  ^ör¯èþ ÉÐóþÍ Ðèþɧæþ ×  __________________________________ __________________________________________________ ________________ (èþÉyì þ ³Ææ  õ    ÿ) ÿ) __________________________ Ðéǧæþ° «æ þÒMæ þÒMæüÇ^èþyæ þÐèþÐè þÆÿ¨. þÆÿ¨. This is to certify that the above signature thumb impression i mpression is of ____________________________________ ____________________________________ S/o. ______________________ _________________________________ _________________ ______

ôþ¨ : Date:

«æþÒMæ  þÒMæüÇçÜ¢¯è¯þè ² Vð ühsð ühsðüy þ  A¬MéÇ çÜèþMæü: Signature of the Certifying Gazetted Officer

A¬MéÇ õ ³Ææ   ÿ: ÿ: MéÆéÅËÄè ÿÿ Ðèþɧæþ OFFICE SEAL

Name of the Officer :

çßø§é: Designation:

Ææÿ´ëÆÿ ÿ ´ëÆÿ Æðÿѯè ÿ Ñ¯è þÅ þÅ Ýëtç ç³  REVENUE STAMP 1 RUPEE

ÆæÿÖ§æ þ  þ  RECEIPT

VæüÐèü Ðèþ°Mæü: ò ³ MæM æü ü Ææÿ.  ÿ. 500&00 ËN Ñ_¯è þrÏ þrÏÆÿô þ D ÆæÿÖ§æ þN þN Ýëtç³  ç   AMì ü^éÍ. ü^éÍ. Note: If the amount exceeds Rs. 500/- this receipt should be duly stamped.

¯ð þ  . VæüË ^èþ§é§éÆæÿ ×/×Ðèþ   ______________________________________________ ¡çÜMö¯è     þ²þ² ÁÐèþ  þ Ððþèþ¢ þ¢ /É´ëÑyð þs þsü ç·yæþ Ðð þè þè þ¢þ¢/Ææ /Ææÿ}ý Ðð þè þè þ¢þ¢/»ø¯è /»ø¯èþ þÜ Ððþé¢ËN ËN Üç º¬_¯èþ  ÆæÿÖ§æ ÿ Ö§æ þ. þ. Receipt regarding the amount of Insurance / Provident Fund / Loan / Bonus of Sri/Smt. ______________________ subscriber No. __________________

×/×Ðè þ  þ ________________________________ AsêȲ/»ô ýÆæýÆæÿÆÿ Æÿ  AÆÿ¯è þ ________________________ ¯óþ¯èþ ¯è þ  þ  iÑèþ  ÁÐèþ  þ ÔéQ yð þþÆ ð ÿMæÿMæütÆ óÿr, ÿr, ò ß  ɧé»ê§ ɧé»ê§þ ÐéÇ ¯è þyì þyìþ Ææÿ. ________________ (Ææ ÿ´ëÄè ÿ´ëÄè ÿË  ÿË  ________________ ÐèþÉè þÐóþÐóþ) ô þ¨  þ¨  þ¨ ¯ð þ. þ. ________________ VæüË  üË ^ðþNP / yì þ.yì þ.yì þ.þ. A§æ þMö¯è þMö¯èþ²rÏ C§æþÐè þ ÐèþËÐè þVé þVé Ææ ÿÖ§æ ÿÖ§æþ þ A§æ þgô þgô ýçý çÜ¢  ¯é²Ææ ¯é²Ææ ÿ. ÿ. ________________ ô þ¨ I, _________________________________ hereby acknowledge receipt of Rs. ____________ (Rupees ______________________ ______________________ only) from the ____________ Directorate of Insurance, Hyderabad per self Sri/Smt. __________________ Attorney / Bearer for Cheque / D.D. No. ______________ Dated __________________ .

 ò³  MæMüæ  ¡çÜN¯è     þ² Ðé° ç Üè    þMæþMæ ü

´ëËܧéÆæ ï ÿ /  Mæ üÆÿÐè ÏüÏÆÿÐèþ§éÆæ   ÿÿ çÜè þMæþMæü ô þyé þyé »ör¯è þÉÐó þÉÐó þÍ þÍ Ðèþɧæ þ ɧæþ

Signature of Receipient

Signature or thumb-impression of the policy holder/claimant

×/×Ðèþ  þ  ________________________ ^óþí þ íÜ¯è   þ ò ³   Üè ç    þMæþMæüÐè üÐèþ / ^ör¯è þÉÐó þÉÐó þÍ þÍ Ðèþɧæ þ ɧæ þ çÜÐèþæ  þæþÐè þÐèþÌø ^ó þÔéÆæ þÔéÆæ ÿ° ÿ° / Ðó þÔéÆæ þÔéÆæÿ° C§æ þÐè þÐè þËVé þËVé «æþÐèþç³ÆæÿçÜ¢¯é²¯èþ. I hereby certify that the above signature / thumb impression of Sri / Smt. _________________________ is made in my presence.

Vðühsð üyüy þ  A¬MéÇ õ³Ææÿ  Name of the Gazetted Officer

çßø§é Designation

«æþÒMæ  þÒMæ üÆæüÆæ ÿ}ý ÿ}ý ôþ¨: «æ þÒMæ þÒMæ üè üè þ A¬MéÇ ç Üè    þMæþMæ üÐèüÐè þ  þ  Date of attestation Signature of Certifying Officer

MéÆéÅËÄèÿÿ  Ðè þɧæ þɧæþ OFFICE SEAL ×  ________________________ çÜÐè þǵ_¯è þǵ_¯è þ «æ þÐè þÐèþç ³Éè   þ B«éÆæ ÿVé ÿVé ò³ ^ðþNP¯è  þNP¯èþ Ðè þÅMì þÅMì ü¢ü¢VæV æüèüè þVé þVé A§æ þgô þgô ýÄè ýÄè ÿyæ ÿyæ þÐèþÐèþÆÿ¨. On the strength of certification certif ication of _____________________ _________________ ____ the above cheque is delivered personally.

VæüÐè ü Ðèþ Ýë¢

çÜ³Çsð ç   üyð ü yð þ r

iÑèþ ÁÐèþ ÔéQ AíÜòÜtr yðþÆðÿMæüÆæÆt  æÿ  ÿ 

Clerk

Superindent

Asst. Director of Insurance