01/2014

LOAN FORM

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Form No. 29

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Inward No.

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APGLI

Office Use Only

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DIRECTORATE OF INSURANCE

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GOVERNMENT OF ANDHRA PRADESH

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HYDERABAD, Andhra Pradesh

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District Insurance Office : __________

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__________

APPLICATION FOR LOAN

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Policy No.

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1. Name of the Subscriber
2.

Fathers Name

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3. Designation x [y

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4. Date of Birth xmso s [j

(As per Service Register)
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5.

Office where he is employed

6.

The Amount of Loan applied for

7.

D. D. O. Code

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The Number of Instalments in which the Loan is proposed to be repaid

(Not exceeding 48, according to Rule 46)

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12

24

36

48

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8.
9.

Basic Pay

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Gross Salary

Total Deductions

Net Salary

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10. Monthly Premium

11.

Pay Scale

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Name of the Bank where Payment of Loan is desired

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Branch Name

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IFS CODE

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Bank Account No.

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12.

Employee I. D. No.

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13.

Aadhar Card No.

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14.

Mobile No.

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E Mail of Policyholder

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Mobile No. of Drawing and

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17.

E Mail of Drawing and

Disbursing Officer

Disbursing Officer

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I hereby declare that the particulars stated above are true and correct.

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I hereby authorise the Director of Insurance, Government of Andhra Pradesh to pass orders to
effect recoveries of Loans and Interest from my salary in the manner as may be prescribed by him in
accordance with the Rules of APGLI Fund.

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Date :

Signature of Applicant

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It is certified that the particulars stated in the above application are correct to the best of my
knowledge and belief and the above Signature of Sri ___________________ is signed in my presence. He
obtained a Loan of
_______________ from APGLID out of which
______________ is still
outstanding.

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Signature of Drawing and Disbursing
Officer with Seal
Station :

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Date :

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1/-

Revenue Stamp

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STAMP RECEIPT

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Note : If the Amount exceeds

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5,000/-, Revenue Stamp shall be affixed.

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Policy No. ___________

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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.

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Signature

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I hereby certify that the above Signature of Sri / Smt ________________________________
is made in my presence.

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Station :

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Signature of Drawing and Disbursing

Officer with Seal

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Date :

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Name :

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Designation :

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