Refund of Amount From the Directorate of Insurance ... - AP Online

¯èþÐèþ ’¯é ¯ðþ. 12FORM No. 12ÁÐèþ’ÔéQ yðþ”ÆðÿMæütÆóÿr , BÉ«æþÉ糧óþÔý, òß”§æþÆé»ê§æþ .DIRECTORATE OF INSURANCE :: ANDHRA PRADESH :: HYDERABADÁÐèþ’ÔéQ É´ë¡Äèÿ yìþ糓Åsîü yðþ”ÆðÿMæütÆæÿ MéÆéÅËÄèÿ Ðèþ ____________________________________________OFFICE OF REGIONAL DEPUTY DIRECTOR OF INSURANCE _________________________¯èþÐèþ ’¯é ¯ðþ. 1FORM NO.1ÁÐèþ’ ÔéQ yðþ”ÆðÿMæütÆóÿr MéÆéÅËÄèÿ , òߔɧé»ê§æþ ¯èþ yì þ Ððþ €èþ¢ Ðéç³çÜ MøÆæÿ €èþ ¯èþ²sìüt «æþÆæÿRêçÜ ¢(©°° ^èþ§é§éÆæÿ 糓Ǣ ^óþÄèÿ’Í)APPLICATION FOR REFUND OF AMOUNT FROM THE DIRECTORATE OF INSURANCE ::HYDERABAD(To be filled by the subscriber)1. ^èþ§é§éÆæÿ õ³Ææÿ , A€èþ° €èþÉyìþõ³Ææÿ , çßø§é :Subscriber's name and name of hisfather and designation :2. ^èþ§é§éÆæÿ çÜÈÓçÜ _ÐèþÇ ÆøkËÌø ç³°^óþíܯèþMéÆéÅËÄèÿ Ðèþ õ³Ææÿ , hÌêÏ õ³Ææÿ :Name of the office and the Districtwhere the subscriber was last in service :3. ^èþ§é§éÆæÿ ° ´ëËïÜ, Ìôý§é ´ëËïÜË ¯ðþºÆæÿ , ÐésìüÐésìü Ððþ €é¢Ë Ìôý§é A€èþ° É´ëÑyðþr ç·yæþçÜ¿æý Åyðþ”¯èþrÏÆÿ €ôþ, ÇhçÙtÆæÿ ¯ðþ.Number of policy or policies and theirrespective amounts or register numberof the subscriber if he was a memberof theProvident Fund.4. ´ëËïÜ Ððþ ^èþ ÅÇsîü €ôþ¨ :Date of Maturity of the Policy :

5. G) çÜÈÓçÜ çÜÐèþ’ç³¢Ððþ ”¯èþ €ôþ¨:a) Date of termination of service¼) Éï³Ñ Äèÿ Ððþ €é¢°² ÐèþçÜ’Ë ^óþíܯèþ _ÐèþÇ ¯ðþËb) Month of last deduction of premium6. D Ððþ €é¢°² 55/58 çÜÐèþ€èþÞÆéËÐèþÄèÿ çÜ Þ ç³“Ç¢ MéNyé¯óþ MóüÏÆÿ Ðèþ^óþçÜ ¢¯é²Æé?Is the amount being claimedbefore the completion of age 55/587. D Ððþ €èþ¢ ^ðþÍÏ糑 MøÆæÿ €èþ ¯èþ²sìütBÉ«æþÉ糧óþÔý É糿æý €èþÓ ÉsðüfÈ õ³Ææÿ Ìôý§éõÜtsü »êÅMü BŽ· òß”§æþÆé»ê§þ Ìôý§éõÜtsü »êÅMü BŽ· CyìþÄèÿ’ É»ê_ õ³Ææÿ :Name of the Andhra PradeshGovernment Treasury or the Branchof the State bank of Hyderabad orState Bank of India from whichpayment is desired.8. ^èþ§é§éÆæÿ _ÐèþÇ (5) Hâèý Ï ç³°^óþíܯèþMéÆéÅËÄèÿ õ³Ææÿ :Office in which the subscriber hasworked during the last (5) years9. §æþÆæÿRêçÜ ¢§éÆæÿ 糓Ǣ _Ææÿ ¯éÐèþ’Full address of the Applicant10) G) Ææÿ’. ..................................... H.í³.h.GÌý.I. ¯èþ yìþ º }ý ´÷¨Ðæþ‘¯é²Ææÿ .D Ððþ €é¢°Mìü Vé¯èþ’, Ææÿ’. .............................. ^ðþÍÏ^èþÐèþËíÜ Ðæþ‘¯èþ ²¨. D Ððþ €é¢°²Ðèþyîþz€ø çÜà ¯é ´ëËïÜ Ððþ €èþ¢ ¯èþ yìþ ÐèþçÜ’Ë ^óþçÜ Mö ^èþ a¯èþ .I have obtained A.P.G.L.I. Loan of Rs. ____________________ , out of whichI have to pay Rs. ______________________ which may be recovered alongwithinterest from my policy amount.

Ææÿ’´ëÆÿ Æðÿѯèþ’Å Ýët糑REVENUESTAMP 1 RUPEEÆæÿÖ§æþRECEIPTVæüÐèþ °Mæü: ò³”Mæü Ææÿ’. 500&00 ËN Ñ _¯èþrÏÆÿ €ôþ D ÆæÿÖ§æþ N Ýët 糑 A Mìü^éÍ.Note: If the amount exceeds Rs. 500/- this receipt should be duly stamped.¯ðþ. VæüË ^èþ§é§éÆæÿ ×/×Ðèþ ______________________________________________¡çÜ Mö¯èþ² ÁÐèþ’ Ððþ €èþ¢/É´ëÑyðþsü ç·yæþ Ððþ €èþ¢ /Ææÿ }ý Ððþ €èþ¢/»ø¯èþŽÜ Ððþ €é¢ËN çܺ¬_¯èþ ÆæÿÖ§ æþ .Receipt regarding the amount of Insurance / Provident Fund / Loan / Bonus of Sri/Smt. ______________________subscriber No. __________________×/×Ðèþ ________________________________ AsêȲ/»ôýÆæÿÆÿ AÆÿ ¯èþ ________________________ ¯óþ¯èþiÑ€èþ ÁÐèþ’ ÔéQ yðþ”ÆðÿMæütÆóÿr , òߔɧé»ê§þ ÐéÇ ¯èþ yìþ Ææÿ . ________________ (Ææÿ’´ëÄèÿ Ë ________________ Ðèþ’É€èþÐóþ ) €ôþ¨________________ €ôþ¨ ¯ðþ. ________________ VæüË ^ðþNP / yìþ.yìþ. A§æþ Mö¯èþ²r Ï C§æþ Ðèþ ’ËÐèþ Vé ÆæÿÖ§æþ A§æþgôýçÜ ¢¯é²Ææÿ .I, _________________________________ hereby acknowledge receipt of Rs. ____________(Rupees ______________________ only) from the ____________ Directorate of Insurance, Hyderabad perself Sri/Smt. __________________ Attorney / Bearer for Cheque / D.D. No. ______________ Dated__________________ .ò³”Mæü ¡çÜ N¯èþ² Ðé° çÜ€èþMæüSignature of Receipient´ëËïܧéÆæÿ / MæüÏÆÿ Ðèþ §éÆæÿ çÜ€èþMæü €ôþyé »ör¯èþÉÐóþÍ Ðèþ ɧæþSignature or thumb-impression of the policy holder/claimant×/×Ðèþ ________________________ ^óþíܯèþ ò³” çÜ€èþMæüÐèþ / ^ör¯èþÉÐóþÍ Ðèþ ɧæþ çÜÐèþ „æþÐèþ Ìø ^óþÔéÆæÿ° / ÐóþÔéÆæÿ° C§æþ Ðèþ ’ËVé«æþ–Ðèþç³Ææÿ çÜ ¢¯é²¯èþ .I hereby certify that the above signature / thumb impression of Sri / Smt. _________________________is made in my presence.Vðühsðüyþ A¬MéÇ õ³ÆæÿName of the Gazetted Officerçßø§éDesignation«æþ–ÒMæüÆæÿ}ý €ôþ¨: «æþ–ÒMæü–€èþ A¬MéÇ çÜ€èþMæüÐèþDate of attestation Signature of Certifying OfficerMéÆéÅËÄèÿ Ðèþ ɧæþ OFFICE SEAL× ________________________ çÜÐèþ ǵ_¯èþ «æþ–Ðèþç³É€èþ B«éÆæÿVé ò³” ^ðþNP¯èþ ÐèþÅMìü¢Væü€èþVé A§æþgôýÄèÿ yæþÐèþ Æÿ ¨.On the strength of certification of _____________________ the above cheque is delivered personally.Væü Ðèþ Ýë¢ çÜ’ç³Çsðüyðþr iÑ€èþ ÁÐèþ’ ÔéQ AíÜòÜtr yðþ”ÆðÿMæütÆæÿClerk Superindent Asst. Director of Insurance