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Application For Policy Application Number: NB2020100001: Proposal Form

Sreenivasa Naik has applied for an insurance policy. He is a 43-year old married pharmacist working at a Primary Health Center. His application provides personal details like name, father's name, address, date of birth, family details. It also includes employment details like designation, employee number, date of first appointment, basic pay, pay scale. Medical details regarding his health and any past or existing diseases are also noted. His nominee details listing his wife and father as beneficiaries are specified. Upon approval, his monthly premium would be 1150 rupees recovered from his salary in December 2004.

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phc kallumarri
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231 views2 pages

Application For Policy Application Number: NB2020100001: Proposal Form

Sreenivasa Naik has applied for an insurance policy. He is a 43-year old married pharmacist working at a Primary Health Center. His application provides personal details like name, father's name, address, date of birth, family details. It also includes employment details like designation, employee number, date of first appointment, basic pay, pay scale. Medical details regarding his health and any past or existing diseases are also noted. His nominee details listing his wife and father as beneficiaries are specified. Upon approval, his monthly premium would be 1150 rupees recovered from his salary in December 2004.

Uploaded by

phc kallumarri
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Application For Policy

Application Number : NB2020100001

DIRECTORATE OF INSURANCE
Form-1
GOVERNMENT OF ANDHRA PRADESH
AMARAVATHI,ANDHRA PRADESH
DISTRICT INSURANCE OFFICE:ananthapuram
Proposal Form No:
PROPOSAL FORM

Name : Sreenivasa Naik Gender : Male


Islavath
Father Name : Islavath Lakshma Designation : Pharmacist
Naik
Employee Office Address : Primary Health PIN Code : 515303
Center, Kallumarri
Date Of Birth : 01-08-1977 Date Of First Appointment : 11-12-2005
Employee Number : 1031241 CFMSID Number : 14397138
Marital Status : Married Number Of Children : 1
Children Details:

[Link] Child Name Date Of Birth Age


1 Sugali Ramadevi 03-06-1985 35
2 Islavath Saiswarnika 10-03-2007 13

Basic Pay : 34170


Pay Scale : 28941-35120
Are You in Good Health : Yes
Have You in the Preceeding(3) Years been absent on Leave on No
:
Medical Grounds for more than(10) days at a time?If Yes,give details
Medical Leave Details :
Are you a physically challenged [Link] so,enclose Certificate No
:
issued by a Competent Authority
If so,enclose Certificate issued by a Competent Authority :
Nominee Details:

[Link] Name Of Nominee Name Of Nominee's Father Age Relationship of Share


Nominee
1 Sugali Ramadevi Hanume naik 35 Spouse 50
2 Islavath Saiswarnika Islavath Sreenivasa Naik 40 Father 50

Diseases Details:
[Link] Disease Disease Disease From Disease To Disease Details
Status
1 HeartAilment No
2 Kidney No
3 Cancer No
4 Lungs No

Proposed Monthly Premium : 1150 Month and Year of Recovery : Dec/2004


Mobile Number : 9000482430 Email Address : sss10sri@[Link]
m
Aadhar Card Number : 277237392177 Employee ID Number : 1031241
Major Head : 2210 D.D.O Code : 10120903005

Declaration by the Proponent

'I do hereby declare that the foregoing details and Answers have been given by me after
fully understanding the questions,the same are true,full and complete whether written in my own hand writing
or not in every particular and that I have not withheld or concealed any circumstance with regard to which
information has been required from me.I agree that the foregoing statements and declaration shall be the
basis of the proposed contract for an Insurance and that if it shall hereafter appear that I have willfully made
any untrue statement or have fraudulently concealed any circumstances which I ought to have made known
then all the premia which shall have been paid under the said contract shall be forfeited and the contract
rendered absolutely null and void.'

Date : 12/9/2020 [Link] PM Signature

CERTIFIED BY OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED

I certify that the service particulars stated above are correct and the Proponent's
Signature has been affixed in my [Link] First Premium recovered for fresh/subsequent Insurance is
1150 in all 1150 (including previous and present Premium) from the pay of Dec
month and 2004 year,vide token No. ______________________dated ____________________.

Station_______________________ Signature
Date__________________________
Drawing and Disbursing Officer(If DDO is not gazetted,
it should be countersigned by next Gazetted Officer
and Self Attestation is not acceptable)

Designation

Office Seal

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