Signature

ofApplicant
INSURANCE Insurant premium
ofAmount
the address
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ihe
under
Scheme. of Present
deoath
Insurant.
Insurance Amount
of
Policy

ASSURANCE
FOR
APPLICATION
12)
lnsurance the
the taken
STATE of
by
event
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Relation
with
the
RÜLE
for the Insurant
applying
Compulsory in
KASHMIR
IN paid
policy of Insurance
Policy
taking
be
TOperson a) b)
b). a)_ b) a)_ b) receipt,of of
below) to
(REFERRED
Employee's Pay
is Age
benefits
Date

employed given
Grade the
a letters) held
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by Ist inattached thebefore
Rs.2,00,000)
schedule
drawn
already
urderhGIes
AND made of
(Blockletters)
Copy day
appointment
&
which
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Govt./Designation
for
whom
Nominee
matures./death Fund
Insurance
Government birth post applied
the to
Surname
(Block(attested
book in Govt. Married/Un-maried
a) the exceeding
with nominees
JAMMU
be
Statemnent
next address
Service of
address
Present
b)
Department/Office Pay
joining of Band palicy
the
of
Name

and Namebirth on particulars pay

accordance
be Permanent
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of Monthly
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to
of
Scale Amount Description
Date Page Age Under Date (Note:-
Full a)Full the
b) a) b) a) b) (in Details
01.a)b) a) before
02. 03. 04. S. No,
05. 06. 97. O8.
b
ASSURED of D.D.O.
Signature Heod
or Officer
he one Stamp
which been
be the
BE Signature/Designation
applicant
of with Attesting
either has of
TO that designation
SUM nothing Designation
than
should other
MINIMUM
FALLS
higher and
Rs.2.00,000/-
and
it or
PAY andOffice
correct
GRADE Rs.2,00.000/- superior Signature
schedule
orRs.2.00,000/ are the
book Of
EXCLUDING immediate
proposer
Rs.l,00,000/
Rs.2,00,000/
Rs.1,50,000/ deliberately
concealed.
Rs.25,000/
Rs.50,000/ of Service
excccd
amount Insurance by
the signedattestedduly
PAY applicont's the
SCHEDULE by copy
BAND an not of State counter
above
for shall page duly order
above the
Insure
anount by given sOurce)
in
and book appointment
MONTHLY
Certiflcate First entry applicant
the service
however, particulars (with for
suchin
indicated as identification: required of Permanent
PM Assured
EMPLOLYEES
15600/- measurement: by
9300/-PM
atbove but era ascertained form page
may. first
conpulsorily Christian documents
application
sum the
to amount
employee of of D.D.0.
to to of
PM PM that copy copy Covering
4.letter.
PMPM be
by
of Attested
True
copy
RequisieD.D.O. attested
by
limit
Rs.5200/ 15601/- certified by marks by Photostat
9301/-
5201/- stipulated
the can of Photostat
birth height Filling
I. D.D.0.
MaximumAn take
Address: as Personal
UptoFrom
From
From of Nearly Necessary
Note: to Place:Date: is Exact
has It Date: Date
Noie: Fund 2. 3
a) b) c) d) e)