APGLI further bond Application

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.    a.  Name in full (Block Letters)      :           __________________________________

           

b.    Male / Female                             :           __________________________________

c.    Father’s Name in Full               :           __________________________________

d.    Address                                       :           __________________________________

__________________________________

e.    Designation                                :           __________________________________

f.     Date of Birth                                :           __________________________________

2.    a.    Are you married                  :           __________________________________

b.    If married, Mention            :           __________________________________

i.      No of Childrens living and

Their present ages

ii.    No. of childrens dead with ages

& year of death                         :           __________________________________

3.    Details of Service in State Government :

a.    Date of First Appointment        :          

b.    Present / Substantive post held if any:                                              Pay / Scale                                             

4.    If already insured with Directorate of             __________________________________

Insurance                                                            :                                    Policy No.

Monthly Premium               

a.    To be filled after verification policy documents        :

b.    Proposed monthly premium now (deducted from

the salary / Challan remitted)

5.    a.  Mentioned the date as on which the previous

     Assurance was issued                          :           __________________________

b.    Have you in good health?                                            :

c.    Has you health been effected since the date           :

     Of mentioned at is so, give full particulars of

    The illness and treatment ndergone along with

     Copies of medical certificate if any.

d.    Give particulars of leave applied for if any on

Medical grounds, if none, state “nil”               :

PRTUGNT

e.    Have there been any serious illness or death

Among the members or your family since the

Date mentioned in answer to (a) above?

Give details if any                                                          :

(For Females only)

6.    Have you periods been regular and painless

And are they go now ?                                      :           _________________________

7.    State the last date of your last menstruation :           _________________________

8.    a. When was your last confinement  (Pregnancy): _________________________

b.    Are you Pregnant now?                                               :           _________________________

c.    Have you had any miscarriages ?                              : _________________________

9.    Details of Nominations ?                                              :          

a.    Name of the Nominee / Moninees                              : _________________________

b.    Name of Nominee 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 in 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 not on leave at the time of declaration and the proponent’s signature has been affixed 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  : ………………

Station :                                                                                 Signature

Dated :                                                                                   Designation :

Office seal

Note :  Nomination is compulsory

 

APGLI Revised Slab Rates in RPS 2010 as per G.O.Ms. No., 231 fin, dt. 28-06-2010.

Pay From       Rs. 6,700       to Rs. 8,440              monthly premium     @ Rs.250

Pay From       Rs. 8,441       to Rs. 10,900            monthly premium    @ Rs.350

Pay From       Rs. 10,901     to Rs. 14,860            monthly premium     @ Rs.450

Pay From       Rs. 14,861     to Rs. 18,030            monthly premium    @ Rs.600

Pay From       Rs. 18,031     to Rs. 25,600            monthly premium     @ Rs.750

Pay From       Rs. 25,601     to and above             monthly premium     @ Rs.1000

Employees who crossed 48 years of age as on proposal date need not pay the enhanced PREMIUM.