1. The document is a nomination form submitted by an individual to nominate beneficiaries for life insurance policies in case of demise. 2. The individual nominates specific persons listed in the schedule and the amounts against their names. 3. It is understood that this nomination will not affect the individual's right to surrender policies or receive amounts upon maturity.

1. B™.Éç³.Éç³.i.Á.Ôé.¯ðþ™.3
A.P.G.L.I.D.NO. 3
B™É«æþÉ糧óþԏý É糿æý€èþÓ ÁÐèþ’ yðþ”ÆðÿMæütÆæÿ MéÆéÅËÄèÿÐèþ
GOVERNMENT OF ANDHRA PRADESH DIRECTORATE OF INSURANCE
ɴ뙡Äèÿ ÁÐèþ’ yìþ糓Åsîü MéÆéÅËÄèÿÐèþ
OFFICE OF THE REGIONAL DEPUTY DIRECTOR OF INSURANCE
To
yðþ”ÆðÿMæütÆæÿ
B™É«æþÉ糧óþԏý 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óþԏý É糿æý€èþÓ iÑ€èþ ÁÐèþ’ ÔéQ (°ÄèÿÐèþ’ÐèþãÌø° (¨VæüÐèþ €ñþÍí³¯èþ) 31Ðèþ °ÄèÿÐèþÐèþ ¯èþ¯èþçÜÇ™_ ________________
MæüÍW¯èþ __________________________ A¯èþ ¯óþ¯èþ, ÉMìü™§æþ A¯èþçÜ’_MæüÌø €ñþÍí³¯èþ ÐèþÅN¢Ë¯èþ ¯óþ¯èþ ^èþ°´ùÆÿ¯èþ ÄðÿyæþË ÐéÇ/
BÐðþ/A€èþ° õ³ÆæÿÏN/õ³ÆæÿN €ñþÍí³¯èþ Ððþ€èþ¢ÐèþË¯èþ ´÷™§æþrN A¯èþ¬Mæü¢ËVé C™§æþ Ðèþ’ËÐèþ¯èþ ¯éѐ¯óþr ^óþÄèÿyæþÐðþ”¯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.
çÜÈÓçܐ ¯èþ™§æþ €ôþ¨Mìü Ðèþ™§æþVé ¯óþ¯èþ E§øÅVæüÐèþ Ðèþ’¯èþMö¯èþ² ÄðÿyæþË ´ëËïÜ˯èþ Aǵ™^èþrN Ìôý§é ´ëËïÜ ç³Çѐ ^ðþ™¨¯èþ Ґ§æþr ¯óþ¯óþ
çÜÓÄèÿÐèþVé Ððþ€èþ¢™ ¡çܐMö¯èþrN ¯éN¯èþ² çßNPN ¯éѐ¯óþçÙ¯èþ H Ñ«æþÐèþVé ¿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¯èþçÜ’_ ¯éѐ¯óþsü
SCHEDULE NOMINEES
ÐèþÆæÿçÜ
ç Ü ™QÅ
¯éҐ±Ë õ³Ææÿ €èþ™Éyìþ õ³Ææÿ€ø
çÜà Names of the
ÐèþÄèÿçܐÞ
Sl.
No.
nominous with father's
name
Age
´ëËïܧéÆæÿyìþ€ø
VæüË çÜ™º™«æþÐèþ
¯éѐ¯óþr ^óþÄèÿ ´ëËïÜË ÑÐèþÆæÿÐèþË
Particulars of Polices to be Nominated
´ëËïÜ Ððþ€èþ¢ç³‘ °çÙµ¢ ÇÐèþ’ÆæÿPː
´ëËïÜ ¯ðþ™. Ððþ€èþ¢™
Relation to
Remarks
Policy No. Amount HÐèþÆÿ¯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’Ææÿyðþ”¯èþ ................................. §æþ° «æþ–Ðèþç³Ææÿ^èþÐðþ”¯èþ¨
Certified that the above signature is of ................................................................ son of ...................................
Væühsðüyþ 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 ÐèþÉ§æþ