01/2014

DEATH CLAIM FORM

ª«sVLRißá ZNýPLiVVª±sV FnyLRiLi
Please affix Legal Heir
Photo, duly attested by Inward No.
the DDO @Li»R½LæS-sV ®©sLi.
ÌÁÕôÁµyLRiV¬s Fn~ÉÜ @¼½NTPLiÀÁ
µ³R¶X-dsNRPLjiLi¿RÁ ª«sÛÍÁ©«sV
Office Use Only
APGLI NSLSùÌÁ¸R¶Vxmso Dxms¹¸¶WgSLóiR Li
DIRECTORATE OF INSURANCE
\® ²¶lLiNíRPlLiÉÞ A£msn B©«sW=lLi©±s=
GOVERNMENT OF ANDHRA PRADESH
ALiúµ³R¶ úxms®µ¶[a`P úxms˳ÁÏ V»R½*ª«sVV
HYDERABAD
\|¤¦¦¦µR¶LSËص`¶
Refund Form – 2
Ljimx nsLi²`¶ FnyLRiLi c 2

DISTRICT INSURANCE OFFICE ___________

ÑÁÍýØ ÕdÁª«sW NSLSùÌÁ¸R¶Vª«sVV ___________
(To be filled by the Heir of the Subscriber)
(¿RÁLiµyµyLRiV ªyLRixqsVÌÁV ˳ÁÏ Lkiò ¿Á[¸¶R Vª«sÛÍÁ©«sV)
All Columns shall be filled in capitals only
@¬sõ NSÌÁª«sVVÌÁV |msµô¶R @ORPQLRiª«sVVÌÁ»][ xmspLjiògS ¬sLixmsª«sÛÍÁ©«sV
Policy No. Employee ID No. Claimant’s Mobile No.
FyÌÁ{qs ®©sLi. Dµ][ùgji H²T¶ ®©sLiÊÁLRiV ÌÁÕôÁµyLRiV¬s ®ªsVV\ÛËÁÍÞ ®©sLiÊÁLRiV

1. Name of the Subscriber ¿RÁLiµyµyLRiV¬s }msLRiV

2. Father’s Name »R½Liú²T¶ }msLRiV 3. Designation ¤x ¦Ü[µy

4. Name of the Office and the District where the Subscriber was working at the
time of Death
¿RÁLiµyµyLRiV ¿RÁ¬sF¡¹¸¶V©yÉÓÁNTP xms¬s¿Á[zqs©«s NSLSùÌÁ¸R¶Vª«sVV }msLRiV, ÑÁÍýØ }msLRiV

5. Date of death of the subscriber specifying the

D D M M Y Y Y Y
disease / cause of death
¿RÁLiµyµyLRiV ¿RÁ¬sF¡LiVV©«s ¾»½[µj¶, ªyùµ³j¶ -sª«sLRiª«sVVÌÁV

6. Name of the Claimant and his / her Father’s Name Relationship with deceased Policy holder
ZNýPLiVVª«sVV ¿Á[¸R¶VV¿RÁV©«sõ ªyLji }msLRiV ª«sVLji¸R¶VV ªyLji »R½Liú²T¶ }msLRiV ¿RÁ¬sF¡LiVV©«s ¿RÁLiµyµyLRiV¬s»][ gRiÌÁ ÊÁLiµ³R¶V»R½*Li

7. Date and reason of retirement

D D M M Y Y Y Y
xmsµR¶-ds -sLRiª«sVßá ¾»½[µj¶, NSLRiß᪫sVVÌÁV

(Contd – 2)
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 :: 2 ::

8. Names of the Wife or Wives of the deceased with their

children and ages
¿RÁ¬sF¡LiVV©«s ª«sùQQNTPò ¹¸¶VNRPä ˳ØLRiù ÛÍÁ[µy ˳ØLRiùÌÁ }msLýiR V, zmsÌýÁÌÁ }msLýiR V ª«sVLji¸R¶VV ª«s¸R¶VxqsV=

9. Name of the Bank where payment is desired

¿ÁÖýÁLixmso N][LiR V¿RÁV©«sõ ËØùLiN`P }msLRiV

Branch Name úËØLiÀÁ }msLRiV

IFS CODE H Fs£mns ¸R¶V£qs N][²`¶

Bank Account No. ËØùLiNRPV ÆØ»y ®©sLiÊÁLRiV

Mobile No. of Claimant ÌÁÕôÁµyLRiV¬s ®ªsVV\ÛËÁÍÞ ®©sLiÊÁLRiV

Aadhar Card No. Aµ³yL`i NSL`ïi ®©sLiÊÁLRiV

10. Full Address of Claimant with Pin Code

ÌÁÕôÁµyLRiV¬s xmspLjiò ÀÁLRiV©yª«sW zms©±s N][²`¶ »][ xqs¥¦¦¦

Important Note : In case of dispute the claim will be settled in terms of Rule 32 (d) (3) of Andhra Pradesh
Government Life Insurance Fund Rule.

ª«sVVÅÁùgRiª«sV¬sNRP iM G®µ¶[¬s -sªyµR¶ª«sVV D©«sõ¹¸¶V²R¶ÌÁ C aSÅÁ ¹¸¶VVNRPä ¬sÊÁLiµ³¶R ©«s 32 (²T¶) (3) úxmsNSLRiLi ¿ÁÖýÁLixmso xmsLjitx sQäLjiLi¿RÁÊÁ²R¶V©«sV.

DECLARATION
úxmsNRPÈÁ©«s
I do hereby declare that there are no other widow or widows of the deceased or minor sons
and unmarried daughters born of them except those mentioned in this Application. If in future any other
Claimants or minor heirs mentioned in the Application Claim payment of their share in the amount on attaining
majority, I shall be held responsible to repay the amount. I also declare that if in future it is found that any
excess payment was made to me in adversantly, I agree to repay such excess amount.

C µR¶LRiÆØxqsVòÍÜ[ ¾»½ÌÁVxmsÊÁ²T¶©«s ªyLRiV ÛÍÁ[NRP ¿RÁ¬sF¡LiVV©«s ª«sùQQNPT Nò PT -s»R½Li»R½Vª«so ÛÍÁ[µy -s»R½Li»R½Vª«soÌÁV ÛÍÁ[µy ªyLjiNTP NRPÖÁgji©«s \®ªsV©«sLRiV
N]²R¶VNRPVÌÁV |msLi²ýT¶ NS¬s NRPVª«sWlLiòÌÁV Fsª«sLRiV Û ÍÁ[LRi¬s BLiµR¶Vª«sVWÌÁª«sVVgS úxmsNRPÉÓÁLi¿RÁ²R¶\®ªsV©«sµj¶. B»R½LRi x¤¦¦¦NRPVäµyLýiR V ÛÍÁ[µy C µR¶LRiÆØxqsVòÍÜ[ ¾»½ÌÁVxmsÊÁ²T¶©«s \®ªsV©«sLRiV
ªyLRixqsVÌÁV ®ªs[VÇÁLýiR V @LiVV©«s -dsVµR¶ÈÁ C \|msNRPª«sVVÍÜ[ »R½ª«sV ªyÉØ©«sV ˳ÁÏ xtsQù»R½VòÍÜ[ N][LiR V xmsORPQª«sVVÍÜ[ A ®ªsVV»R½ªò «sVV©«sV ¼½Ljigji ¿ÁÖýÁLi¿RÁVÈÁNRPV ®©s[©«sV Ëص³¶R Vù²R¶ \®©s
DLi²R¶gRiÌÁ©«sV. INRP®ªs[ÎÁÏ F~LRiFyÈÁV©«s G\®ªsV©y FsNRPV䪫s ®ªsVV»R½ªò «sVV F~Liµj¶¸R¶VV©«sõ ¹¸¶V²R¶ÌÁ @ÉíÁÓ ®ªsVV»R½ªò «sVV©«sV ¼½Ljigji ¿ÁÖýÁLi¿RÁVÈÁNRPV Ëص³R¶ù»R½ ª«sz¤¦¦¦Li»R½V©«s¬s
BLiµR¶Vª«sVWÌÁª«sVVgS úxmsNRPÉÓÁLi¿RÁV¿RÁV©yõ©«sV.

Signature or / Left Hand Thumb Impression of the Applicant

µR¶LRiÆØxqsVòµyLRiV xqsLi»R½NRPª«sVV / ú®ªs[ÖÁ ª«sVVúµR¶
CERTIFICATE
xqsLíjizmnsZNPÉÞ
Certified that the entries made in the Application are correct, the details of which are known
to me. There is no other legal heir of the deceased except those mentioned in the Application and the Signature
or Thump – Impression is of Sri / Smt _________________________________________________________
widow of / guardian of _____________________________________________________________ regarding
which I am fully satisfied.

It is also certified that the last working days Salary was paid to the Claimant only and the
deceased Subscriber was in Service till death.

The Subscriber obtained a Loan of ________________ against his APGLI Policy and if
any outstanding Loan or Interest is payable, the same can be recovered from the Policy amount.

(Contd – 3)

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 :: 3 ::
µR¶LRiÆØxqsVòÍÜ[ ¿Á[zqs©«s ©«s®ªsWµR¶VÌÁV xqsúNRPª«sV\®ªsV©«sª«s¬s¸R¶VV, A -sª«sLRiª«sVVÌÁV ®©s[©«sV FsLjigji©«s®ªs[©«s¬s¸R¶VV µ³¶R X-dsxmsLRi¿RÁ²R¶\®ªsV©«sµj¶. C
µR¶LRiÆØxqsVòÍÜ[ ¾»½ÌÁVxmsÊÁ²T¶©«s ªyLRiV ©yù¸R¶VÊÁµôR¶\®ªsV©«s B»R½LRi ªyLRiqx sVÌÁV Fsª«s*LRiW ÛÍÁ[LRi¬s¸R¶VW xqsLi»R½NRPª«sVV ÛÍÁ[µy ú®ªs[ÖÁ ª«sVVúµR¶
$ / $ª«sV¼½ _____________________________________________________________ -s»R½Li»R½Vª«so / xqsLiLRiORPQNRPV²R¶V
@LiVV©«s ______________________________________________ ®µ¶[ ©«s¬s¸R¶VV ©yNRPV xmspLjigò S xqsLi»R½Xzmsò NRPÖÁgji©«sµj¶. »R½µR¶VxmsLji
¿RÁLiµyµyLRiV¬s ÀÁª«sLji L][ÇÁÙÌÁ ÒÁ»R½ ˳ÁÏ »R½ùª«sVVÌÁV úxmsxqsVò»½R ÌÁÕôÁµyLRiV¬sNTP ¿ÁÖýÁLi¿RÁ²R¶ª«sVLiVV©«sµR¶¬s ª«sVLji ¸R¶VV ¿RÁ¬sF¡LiVV©«s ¾»½[µj¶ ª«sLRiNRPV xqsLki*xqsVÍÜ[®©s[ D©yõ²R¶¬s
µ³R¶X-dsNRPLjiLi¿RÁV¿RÁV©yõ©«sV.

Signature of the Drawing and Disbursing Officer

Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²y @µ³j¶NSLji xqsLi»R½NRPª«sVV

Name of the Officer

in Block Letters :
Office Seal -s²T¶ @ORPQLRiª«sVVÌÁÍÜ[ @µ³j¶NSLji }msLRiV
NSLSùÌÁ¸R¶VLi ª«sVVúµR¶

Designation :
x¤¦Ü[µy M

Name of the Office :

NSLSùÌÁ¸R¶V }msLRiV M

Note :- 1. The Application should be certified by the concerned Drawing and Disbursing Officer only.

gRiª«sV¬sNRP iMc 1. C µR¶LjiÆØxqsVò©«sV xqsLiÊÁLiµ³j¶»R½ Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²y @µ³j¶NSLji ª«sWú»R½®ªs[V µ³R¶X-dsNRPLjiLi¿RÁª«sÛÍÁ©«sV.
2. If the Subscriber dies with (3) Years of issue of Policy / Policies, the Drawing and Disbursing Officer
shall furnish the details of Leave on Medical Grounds availed for a period of (3) Years (alongwith
attested Xerox Copies of Medical Certificate) proceeding the date of commencement of Policy /
Policies.

2. ¿RÁLiµyµyLRiV²R¶V FyÌÁ{qs úFyLRiLi˳ÁÏ xmso ¾»½[µj¶ ©«sVLi²T¶ (3) xqsLiª«s»R½=LRiª«sVVÍÜ[mx so ª«sVLRißÓáLiÀÁ©«s¹¸¶V²R¶ÌÁ, Ax¤¦¦¦LRißá ª«sVLji¸R¶ VV ÊÁÉØ*²y @µ³j¶NSLji,
xqsµR¶LRiV ¿RÁLiµyµyLRiV²R¶V FyÌÁ{qs úFyLRiLi˳ÁÏ xmso ¾»½[µj¶NTP ª«sVW²R¶V qx sLiª«s»R½=LRiª«sVVÌÁ NSÌÁª«sVV©«sNRPV \®ªsµR¶ù NSLRiß᪫sVVÌÁ \|ms ªy²R¶VN]¬s©«s |qsÌÁª«so
-sª«sLRiª«sVVÌÁ©«sV (µ³R¶X-dsNRPLjiLiÀÁ©«s ÑÁLSN`P= \®ªsµR¶ù xqsLíij zmnsZNPÉÞ ÌÁ»][) »R½mx sö¬s xqsLjigS, C µR¶LSÆØxqsVò»][ xmsLixmsª«sÛÍÁ©«sV.
3. The following documents also shall be compulsorily enclosed.

3. µj¶gRiVª«s ¾»½ÖÁzms©«s mx sú»R½ª«sVVÌÁV NRPW²y »R½xmsöNRP ÇÁ»R½ ¿Á[¸¶R Vª«sÛÍÁ©«sV.

Enclosures :
ÇÁ»R½ ¿Á[¸¶R Vª«sÌÁzqs©«s :

a). Policy Bonds Original

Fs). FyÌÁ{qs xmsú»R½ª«sVV

b). Legal Heirs Certificate Copy duly attested

ÕÁ). ªyLRixqs»R½*xmso mx sú»R½ª«sVV µ³R¶X-dsNRPLRißá»][

c). Death Certificate Copy duly attested

zqs). ª«sVLRißá µ³R¶X-dsNRPLRißá xmsú»R½ª«sVV µ³R¶X-dsNRPLRißá»][

(Contd – 4)

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 :: 4 ::

1/-

Revenue Stamp
lLi®ªs©«sWù ríyLi£ms

STAMP RECEIPT
LRibdPµR¶V

Note : If the Amount exceeds 5,000/-, Revenue Stamp shall be affixed.

gRiª«sV¬sNRP iM \|msNRPLi 5,000/c ÌÁNRPV -sVLiÀÁ©«sÈýÁLiVV¾»½[ ríyLixmso @¼½NTPLi¿yÖÁ

Policy No. ___________

FyÌÁ{qs ®©sLiÊÁLRiV iM ___________

I ______________________ have received a sum of _______________ (Rupees

___________________________________________________________ Only) from Directorate of Insurance,
Andhra Pradesh, Hyderabad vide Cheque / D. D. / Online Payment No. ___________________ dated :
______________ towards sanction of Loan / Settlement of Claim against my Policies.

$ / $ª«sV¼½ ______________________ @©«sV ®©s[©«sV ÒÁ-s»R½ ÕdÁª«sW aSÅÁ \®²¶lLiNíPR lLi[ÈÁV, \|¤¦¦¦µR¶LSËصR¶V ªyLji ©«sVLi²T¶
________________ (LRiWFy¸R¶VÌÁV __________________________________________________________
ª«sWú»R½®ªs[V) ¾»½[µj¶ iM ______________________ ®©sLiÊÁLRiV ______________________ gRiÌÁ ¿ÁNRPVä / ²T¶. ²T¶. / A©±s \ÛÍÁ©±s }ms®ªsVLiÉÞ
µy*LS @LiµR¶VN]©«sõÈýÁV BLiµR¶Vª«sVWÌÁª«sVVgS LRibdPµR¶V @LiµR¶Â¿Á[qx sVò©yõ©«sV.

Signature
xqsLi»R½NRPª«sVV

I hereby certify that the above Signature of Sri / Smt ________________________________

is made in my presence.

$ / $ª«sV¼½ _____________________________________ ¿Á[zqs©«s \|ms xqsLi»R½NRPª«sVV ©y xqsª«sVORPQª«sVVÍÜ[ ¿Á[aSLRi¬s

µ³R¶X-dsNRPLjiLi¿RÁV¿RÁV©yõ©«sV.

Station : Signature of Drawing and Disbursing

xqósÌÁª«sVV iM Officer with Seal
Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²R¶ @µ³j¶NSLji xqsLi»R½NRPª«sVV
NSLSùÌÁ¸R¶V ª«sVVúµR¶»][
Date : Name :
¾»½[µj¶ iM }msLRiV iM

Designation :
x¤¦Ü[µy iM

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