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 iрèþ ÁÐèþ’ ÔéQ, òߔ§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 iрèþ ÁÐèþ’ ÔéQ (°ÄèÿÐèþ’ÐèþãÌø° (¨VæüÐèþ €ñþÍí³¯èþ) 31Ðèþ °ÄèÿÐèþÐèþ ¯èþ¯èþçÜǙ_ ________________
MæüÍW¯èþ __________________________ A¯èþ ¯óþ¯èþ, ÉMìü™§æþ A¯èþçܒ_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 per-
sons 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° ¿êљ^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çܒ_ ¯éѐ¯óþsü
SCHEDULE NOMINEES
´ëËïܧéÆæÿyìþ€ø ¯éѐ¯óþr ^óþÄèÿ ´ëËïÜË ÑÐèþÆæÿÐèþË
ÐèþÆæÿçÜ ¯éҐ±Ë õ³Ææÿ €èþ™Éyìþ õ³Ææÿ€ø Particulars of Polices to be Nominated
ç Ü ™QÅ çÜà Names of the ÐèþÄèÿçÜÞ VæüË çܙº™«æþÐèþ
´ëËïÜ ¯ðþ™. Ððþ€èþ¢™ ´ëËïÜ Ððþ€èþ¢ç³‘ °çÙµ¢ ÇÐèþ’ÆæÿPː
Sl. Relation to
No. Amount HÐèþÆÿ¯èþ E™sóü Policy
nominous with father's Age Remarks
No. name Policy-holder Policy
Amount if any
1
2
3
4
5
6
7
197 ......... ¯ðþË ..................................... €ôþ©¯èþ çܙ€èþMæüÐðþ”¯èþ¨.
Signed this .................................................. day of ...................... 197
´ëËïܧéÆæÿ çܙ€èþMæüÐèþ
Signature of the Policy-holder
ò³” çܙ€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 Væühsðüyæþ A¬MéÇ çܙ€èþMæüÐèþ
Designation of the Gazetted Officer Signature of the Gazetted Officer
€ôþ¨ ................................ 197 OFFICE SEAL
Dated ..................................... 197
MéÆéÅËÄèÿ ÐèþÉ§æþ