DATA FOR THE APGLI LOAN APPLICATION
(ALL THE FIELDS SHOULD BE FILLED IN CAPITAL LETTERS ONLY)
District insurance office
VIJAYAWADA
Policy No
L801633
1 Name of the Subscriber TIRUMALASETTI VENKATA KRISHNA RAO
2 Father's Name T V S CHALAPATHI RAO
3 Designation PET
4 Date of Birth 1 1 - 0 1 - 1 9 6 0
5 Date of Maturity 3 1 - 1 2 - 2 0 1 7
6 Date of Retirement 3 1 - 1 2 - 2 0 2 0
7 Name of the Office and the District
where the Subscriber was last in ZPH SCHOOL, EDULAGUDEM, AGIRIPALLI MANDAL
Service
8 Month of last deduction of Premium
May 2019
9 Name of the Bank where Payment of
Loan is desired STATE BANK OF INDIA
10 Branch Name NUZVID
11 IFS CODE SBIN0000889
12 Bank Account No. 10720058902
13 Employee I. D. No. 0527148
14 Aadhar Card No 355228151507
15 Mobile No. 9490336749
16 Full Address of the Applicant with
Pin Code T V KRISHNA RAO, D NO : 24-328, LIC MAIN ROAD,
EMPLOYEES COLONY, NUZVID, NUZVID MANDAL,
KRISHNA DISTRICT, PIN NO : 521201
17 Office in which the subscriber has
worked during the last (5) years 1 SRRZPHS, NUZVID
2 ZPHS EDULAGUDEM
3
13000-40270
13390-41380
13780-42490
14600-44870
15030-46060
15460-47330
16400-49870
17890-53950
18400-55410
19500-58330
21230-63010
22460-66330
23100-67990
24440-71510
25140-73270
26600-77030
28940-78910
29760-80930
31460-84970
35120-87130
37100-91450
40270-93780
42490-96110
46060-98440
49870-100770
52590-103290
56870-105810
61450-105810
66330-108330
73270-108330
80930-110850
87130-110850
CLAIM FORM
Form No. 12
Inward No.
APGLI Office Use Only
DIRECTORATE OF INSURANCE
GOVERNMENT OF ANDHRA PRADESH
HYDERABAD, Andhra Pradesh
Refund Form No. 1 District Insurance Office VIJAYAWADA
APPLICATION FOR REFUND OF AMOUNT FROM THE DIRECTORATE OF INSURANCE, HYDERABAD
(To be filled by the Subscriber)
Policy No L801633
1. Name of the Subscriber
T I R UMA L A S E T T I V E N K A T A K R I S H N A R A O
2. Father’s Name
T V S C H A L A P A T H I R A O
3. Designation
P E T
4. Name of the Office and the District where the Subscriber ZPH SCHOOL, EDULAGUDEM,
AGIRIPALLI MANDAL
was last in Service
D D MMY Y Y Y D D MMY Y Y Y
5. Date of Maturity 3 1 1 2 2 0 1 7 6. Date of Birth 1 1 0 1 1 9 6 0
(As per Service Register)
7 a) Date of Retirement D D MMY Y Y Y
3 1 1 2 2 0 2 0
Nature of Retirement ( √ ) Superannuation Voluntary Compulsory
b) Month of last deduction of Premium May - 2019
8. Name of the Bank where Payment is desired STATE BANK OF INDIA
Branch Name NUZVID
IFS CODE SBIN0000889
Bank Account No. 10720058902
9. Employee I. D. No. 0527148
10. Mobile No. 9 4 9 0 3 3 6 7 4 9
11. Aadhar Card No 3 5 5 2 2 8 1 5 1 5 0 7
12. Office in which the subscriber has worked during the last (5) years
1 SRRZPHS, NUZVID
2 ZPHS EDULAGUDEM
3
13. Full Address of the Applicant with Pin Code T V KRISHNA RAO, D NO : 24-328, LIC MAIN ROAD,
EMPLOYEES COLONY, NUZVID, NUZVID MANDAL,
KRISHNA DISTRICT, PIN NO : 521201
14 A) I have obtained Rs._____________ towards A. P. G. L. I. Loan and there is a balance
Rs._____________ to be paid which may be recovered alongwith interest from my Policy amount.
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.
Date : Signature of Applicant
Certified that the above Signature of Sri / Smt TIRUMALASETTI VENKATA KRISHNA RAO
S/O T V S CHALAPATHI RAO is signed in my presence.
Station :
Date : Signature of the Gazetted Officer
Officer with Seal
Name :
(In Block Letters)
Designation :
Revenue Stamp
STAMP RECEIPT
Note : If the Amount exceeds 5,000/-, Revenue Stamp shall be affixed.
Policy No. L801633
I, TIRUMALASETTI VENKATA KRISHNA RAO 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.
Signature
I hereby certify that the above Signature of Sri / Smt TIRUMALASETTI VENKATA KRISHNA RAO is
made in my presence.
Station : Signature of Drawing and Disbursing
Officer with Seal
Date : Name :
Designation :
Declaration regarding loss of policy
I TIRUMALASETTI VENKATA KRISHNA RAO S/o, D/o T V S CHALAPATHI RAO
hereby declare that the policy/ies No. L801633 has/have been lost and not
mortgaged with any Bank, Firm, Third Party or any financial institution towards any loan.
Signature of subscriber
/Attested/
Signature of certifying Gazetted Officer
Name, Designation and Office seal
