01/2014

CLAIM FORM

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Form No. 12

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Inward No.

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APGLI

Office Use Only

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DIRECTORATE OF INSURANCE

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GOVERNMENT OF ANDHRA PRADESH

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HYDERABAD, Andhra Pradesh

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Refund Form No. 1

District Insurance Office :

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__________
__________

APPLICATION FOR REFUND OF AMOUNT FROM THE DIRECTORATE OF INSURANCE, HYDERABAD

(To be filled by the Subscriber)

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Policy No.

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1.

Name of the Subscriber

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2.

Fathers Name

3. Designation x [y

4.

Name of the Office and the District where the Subscriber was last in Service

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5.
7.

Date of Maturity

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a) Date of Retirement

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Nature of Retirement

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6.

Date of Birth

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Superannuation

Voluntary

Compulsory

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b) Month of last deduction of Premium

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8.

Name of the Bank where payment is desired

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Branch Name

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IFS CODE

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Bank Account No.

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9.

Employee I. D. No.

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10.

Mobile No.

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11.

Aadhar Card No.

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12.

Office in which the subscriber has worked during the last (5) years

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13.

Full Address of the Applicant with Pin Code

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14.

A)

I have obtained

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to be paid which may be recovered alongwith interest from my Policy amount

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__________ towards A. P. G. L. I. Loan and there is a balance

____________
_____________

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14.

B)

I do hereby declare that if in future it is found that any excess payment was made to me in advertantly,
I shall be held responsible to repay such excess amount and give my consent for deduction of the same
from my Pension.

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Date

Signature of Subscriber / LTI

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Certified that the above Signature of Sri / Smt _____________________________________

S/O ____________________________________________ is signed in my presence.

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Station :

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Date

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Office Seal

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Signature of the Gazetted Officer

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Name of the Officer

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Designation

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(Contd 3)
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1/-

Revenue Stamp

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STAMP RECEIPT

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Note : If the Amount exceeds

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5,000/-, Revenue Stamp shall be affixed.

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Policy No. ___________

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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.

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Signature

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I hereby certify that the above Signature of Sri / Smt ________________________________
is made in my presence.

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Station :

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Signature of Drawing and Disbursing

Officer with Seal

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Date :

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Name of Drawing and

Disbursing Officer :

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Designation :

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