FORM N0.

Application for payment of accumulation under state government employees

Group insurance scheme,1983.

To,
The D.I.S

Sir,
I have been a member of the state government employees’ group insurance scheme 1982, 01-
04-1983. I have retired from service after attaining the age of 60(sixty) years, I have ceased to be
in employment with the state government with effect from 31-07-2020. I was holding the post of
Head teacher till the date of my retirement, Before my retirement/cessations of me under the
state government employees’ Group insurance scheme’ be paid to me.

Yours faithfully

Head Teacher(Retired)
Date :