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Nominee form
- 1. B™.Éç³.Éç³.i.Á.Ôé.¯ðþ™.3
A.P.G.L.I.D.NO. 3
B™É«æþÉ糧óþÔý É糿æý€èþÓ ÁÐèþ’ yðþ”ÆðÿMæütÆæÿ MéÆéÅËÄèÿÐèþ
GOVERNMENT OF ANDHRA PRADESH DIRECTORATE OF INSURANCE
ɴ뙡Äèÿ ÁÐèþ’ yìþ糓Åsîü MéÆéÅËÄèÿÐèþ
OFFICE OF THE REGIONAL DEPUTY DIRECTOR OF INSURANCE
To
yðþ”ÆðÿMæütÆæÿ
B™É«æþÉ糧óþÔý É糿æý€èþÓ iÑ€èþ ÁÐèþ’ ÔéQ, òß”§æþÆé»ê§þ (B™.Éç³.)
THE DIRECTOR,
ANDHRA PRADESH GOVERNMENT LIFE INSURANCE DEPARTMENT
Hyderabad (Andhra Pradesh)
B™É«æþÉ糧óþÔý É糿æý€èþÓ iÑ€èþ ÁÐèþ’ ÔéQ (°ÄèÿÐèþ’ÐèþãÌø° (¨VæüÐèþ €ñþÍí³¯èþ) 31Ðèþ °ÄèÿÐèþÐèþ ¯èþ¯èþçÜÇ™_ ________________
MæüÍW¯èþ __________________________ A¯èþ ¯óþ¯èþ, ÉMìü™§æþ A¯èþçÜ’_MæüÌø €ñþÍí³¯èþ ÐèþÅN¢Ë¯èþ ¯óþ¯èþ ^èþ°´ùÆÿ¯èþ ÄðÿyæþË ÐéÇ/
BÐðþ/A€èþ° õ³ÆæÿÏN/õ³ÆæÿN €ñþÍí³¯èþ Ððþ€èþ¢Ðèþ˯èþ ´÷™§æþrN A¯èþ¬Mæü¢ËVé C™§æþ Ðèþ’ËÐèþ¯èþ ¯éѯóþr ^óþÄèÿyæþÐðþ”¯èþ¨.
In terms of Rules 31, Andhra Pradesh Government Life Insurance Department Rules (Reproduced below)
I, .......................................................... (designation) .................................................. hereby nominate the persons specified in the schedule as beneficiaries to receive the amounts state against their / his /her, names in case of my
demise.
çÜÈÓçÜ ¯èþ™§æþ €ôþ¨Mìü Ðèþ™§æþVé ¯óþ¯èþ E§øÅVæüÐèþ Ðèþ’¯èþMö¯èþ² ÄðÿyæþË ´ëËïÜ˯èþ Aǵ™^èþrN Ìôý§é ´ëËïÜ ç³ÇÑ ^ðþ™¨¯èþ Ò§æþr ¯óþ¯óþ
çÜÓÄèÿÐèþVé Ððþ€èþ¢™ ¡çÜMö¯èþrN ¯éN¯èþ² çßNPN ¯éѯóþçÙ¯èþ H Ñ«æþÐèþVé ¿æý™VæüÐèþ MæüÍW™^èþ§æþ° ¿êÑ™^èþÐèþÌñý¯èþ.
It is however, understood that this nomination, will in no way affect my right to surronding the policies in case
of my ceasing to be in service before the date of maturity or to receiving amount myself on maturity of the policy.
A¯èþçÜ’_ ¯éѯóþsü
SCHEDULE NOMINEES
ÐèþÆæÿçÜ
ç Ü ™QÅ
¯éÒ±Ë õ³Ææÿ €èþ™Éyìþ õ³Ææÿ€ø
çÜà Names of the
ÐèþÄèÿçÜÞ
Sl.
No.
nominous with father's
name
Age
´ëËïܧéÆæÿyìþ€ø
VæüË çÜ™º™«æþÐèþ
¯éѯóþr ^óþÄèÿ ´ëËïÜË ÑÐèþÆæÿÐèþË
Particulars of Polices to be Nominated
´ëËïÜ Ððþ€èþ¢ç³‘ °çÙµ¢ ÇÐèþ’ÆæÿPË
´ëËïÜ ¯ðþ™. Ððþ€èþ¢™
Relation to
Remarks
Policy No. Amount HÐèþÆÿ¯èþ E™sóü Policy
Policy-holder
Amount if any
1
2
3
4
5
6
7
197 ......... ¯ðþË ..................................... €ôþ©¯èþ çÜ™€èþMæüÐðþ”¯èþ¨.
Signed this .................................................. day of ...................... 197
´ëËïܧéÆæÿ çÜ™€èþMæüÐèþ
Signature of the Policy-holder
ò³” çÜ™€èþMæüÐèþ .............................................. VéÇ NÐèþ’Ææÿyðþ”¯èþ ................................. §æþ° «æþ–Ðèþç³Ææÿ^èþÐðþ”¯èþ¨
Certified that the above signature is of ................................................................ son of ...................................
Væühsðüyþ A¬MéÇ õ³Ææÿ
Name of the Gazetted Officer
Væühsðüyæþ A¬MéÇ çßø§é
Designation of the Gazetted Officer
€ôþ¨ ................................ 197
Dated ..................................... 197
Væühsðüyæþ A¬MéÇ çÜ™€èþMæüÐèþ
Signature of the Gazetted Officer
OFFICE SEAL
MéÆéÅËÄèÿ Ðèþɧæþ