01/2014 ‘APPLICATION FOR POLICY . Dob dees Form —4 P80-7 DIRECTORATE OF INSURANCE BOYES OF airyOSy GOVERNMENT OF TELANGANA Boome Bedssys9 HYDERABAD pesoen DISTRICT INSURANCE OFFICE gr Bis mongoatsis PROPOSAL FORM (S8bss Sess All Columns shall be filled in capitals only (ody sroiises BE exsEned! Sgr DeSsee Policy No. Proposal Form No. bob Be, Boma Zo. 1. Name 335 Surname sod Full Name rg “o> 2 sex [Mae] Samm [ Female / &) rs Name $25 4. Designation s#c> 5. Employee Office Address aatsh moxgocis Desai . Date of Birth oes do [| DM] MY] ¥| YY) (As per Service Register) [lak Shy5 cag errdo SCh0 ‘ 7, Date of First Appointment Soa Saimsey $2 [ST oT wl wl y[ ¥[y]¥ 8, Marital Status Rovinubor / wdavindber | Ddodisr | Drees (Married [ Unmarried [ Widow "| Divorced 9% Imarried, Mo. of Children and theirages. gu Song Sashtay (Bo. Derinied Spo Sosy teats 8 dado) 10. Basic Pay and Pay Scale same Seissss sotaie Sais bje0 11, DETAILS OF NOMINATION =isiSaio Dore S.No. Name of Nominee Name of Nominee’s Father Age (is S005 Sma bs a Bey dos es ae a) =a Relationship of Nominee Share Satin Soreness asset Sonoge en 12. Are you in Good Health (si3d0 fo wetitgo ancien spyor CV) Tick [Ves / 0a (Contd -2)13, Have you inthe preceeding (3) years been absent on Leave on “Medical Grounds for more than (10) days at a time ? If Yes, give details 18 Sst SoSSyree tach Bey dere utd (10) Sees Se Dee B Rastadaings 7 wand v Biv: Setos ‘4. 1. Have you ever suffered from any ofthe following Diseases :- bod ozs) ayesoe AdwBe he yao weage 7 3. Heart Ailment esoasns 1. Kidney saved Cancer gy 4 Lungs. arse ages Yes [3a worse [| Yes [3a No] 3S [Ye7eos [ [Noles | | Yes [was [| [No we | Yes [235 Ney eS 2. If Yes, give details of Disease, duration and Treatment received Storie wins west, ag Deven, D8) BEDS Bas te Door Beye 1. Are you a physically challenged person. If so, enclose Certificate issued by a Competent Authority E58 Bpar whos etsema Rigveda a2ygend wg wenBtege Dieres Besos, Boyes en Shs wonBenze sySswerd sivenodos 16, Tralready insured Policy No. 1 bast bi dhasyst eb Bo. 17. Proposed Monthly Premium ga2neeDs Bese (bos 18 Month and Year of Recovery sitet uth e dstas Sos 19, Mobile No, =2B5 Ze. ‘Total Monthly Premium Bese (binatetoge 20. Emall Address eiiocnd Oebartee 22. Employee ID No. aatsh gow Zo. 2 Major Head eae [ I Try.D-D.0. Code (Seb 4.4. &. 85 GONSHD ng cote Declaration by the Proponent ‘eho gem ego Sams dogs de Bs GODS divine atydioanes. WrbeBEs meBtawsss BS woe adego, Sisto, Soiryo ecoEAdaw D SeywoH Sonoged die simeets wccrdamiobainsy$ w sopiieis Dondastadais dx senszor gostsdets So sow sane GUO. Dine ssbats i (Stbd bam Pee BaOSODS usyomdt [BAMeNT Gomretass Sis wEErEeKom, TBH sey COKE Didats Dhigemd, Badbsssetips, Tar sehSd Srsy mget nd wodspmd, socbde sos, Tse se Poung od Spotted (htnatiioed eA Het wEsDatn, w uszede Soinfer oes Méosdein Hs esyPamy! wed aragsanset (Conta 3)3 "I do hereby declare that the foregoing details and Answers have been given by me after fully understanding the questions, the same are true, full and complete whether written in my own hand writing or notin every particular and that 1 have not withheld or concealed any circumstances with regard to which information has been required from me. I agree that the foregoing statements and declaration shall be the basis of the proposed contract for an Insurance and that if it shall hereafter appear that I have willfully made any untrue statement or hhave fraudulently concealed any circumstances which T ought to have made known then all the Premia which shall have been paid under the said contract shal be forfeited and the contract rendered absolutely null and void.” 06 bio Sesaods sgt Soato a ae sates) Date Signature with Date GOONS HD wed dioyYoo" Sodso Habnsss’ w word gybssoo dso (CERTIFIED BY OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED BS boys, Sys Bow SeEsias, Garde o Siyod Sesto Tmates te qyesdegsors, dns | eddy bi Singiw égom Hos Bode hina & sted Tages = (08 288 stow Bes State HE Sdabo MOPD) Be ebat Seid ;6iin Basim to 36 ie oS Bone ore Sire Cabdioenta. 1 certify that the service particulars stated above are correct and the Proponent’s Signature has been affixed in my presence. The First Premium recovered for fresh /subsequent Insurance is in ail NTO (including previous and present Premium) from the pay of monthand Year, vide token NO. dated geo sess. Station irda tte wings where (wise bois Bengs were MDE nd Easy wb 62s ee were Sostin Petseainds Seat ates ate ssteto bys gybtee Bye) For OFFFICE USE oR) | Age at Entry Premium ‘Sum Assured Basaine | Drawing and. Disbursing Officer (if DO is not gazetted, it should be 4 countersigned by next Gazetted Officer and Self ‘Attestation is not Ane e acceptable) with Date Ho Total € « Besiteston oneass sae AAs per TSGLI / APGLI Fund Rule 5 Proposal has been scrutnised and.O.R. Omoe cent | submitted for approval. clerk ‘Supa. pro Please visit our Website : voww,tsali.telangana.gov.in for further information and guidelines