APGLI Loan Application

B.Éç³.Éç³.i.Á.ÔéQ ¯ðþ.
41
DIR. OF INS. NO. 41
BÉ«æþÉç³§óþÔý Éç³¿æýèþÓ ÁÐèþ yðþÆðÿMæütÆæÿ MéÆéÅËÄèÿÐèþ
GOVERNMENT OF A.P. DIRECTORATE OF INSURANCE
É´ë¡Äèÿ ÁÐèþ yìþ³ç Åsìü yðþÆ ÿð MæüÆt ÿæ MéÆéÅËÄèÿÐèþ. ..............

OFFICE OF THE REGIONAL DEPUTY DIRECTOR OF INSURANCE ............
º}ýÐèþ MöÆæÿN §æþÆæÿRêçÜ¢
Application for Loan
(çÜ^èþ¯èþË MöÆæÿN Éí³µ ^èþyæþyæþ)
(For instructions, Please see overleaf)
1. ^èþ§é §éÆæÿ° õ³Ææÿ èþÉyìþ õ³Ææÿ çßø§é
Name, father's name and the designation of the subscriber ________________________________
2. Aèþyæþ ç³°^óþçÜ¢¯èþ² MéÆéÅËÄèÿÐèþ õ³Ææÿ
The name of the office where he is employed ________________________________
3. ^èþ§é §éÆæÿ ¯ðþºÆæÿ ÌôýMæü ´ëËïÜ ¯ðþºÆæÿ
Subscriber No. or Policy No. ________________________________
4. §æþÆæÿRêçÜ¢Ìø MøÇ¯èþ Ææÿ´ëÄèÿË Ððþèþ¢Ðèþ
The amount of the loan applied for ________________________________
5. º}ýÐèþ §óþ°MöÆæÿN AÐèþÜç ÆæÿÐèþ (Ððþ¯èþMæü VæüË Üç ^èþ¯èþË¯èþ
§æþíÙtÌø Äèÿ^èþMö° §æþÆæÿRêçÜ¢Ìø ÌôýMæü ©°ø
ç³ç³ ÌôýQÌø ÑÐèþÆæÿÐèþË¯èþ ñþËç³ÐèþÌñý¯èþ).
The object or objects for which the loan
is required (full particulars may please begiven
in the covering letter or application keeping in
view the instructions printed overleaf) ________________________________
6. º}ýÐèþ ÇW H°² ÐéÆÿ§éËÌø ^ðþÍÏ^èþ §æþË^èþMö¯é²Ææÿ
The number of instalments in which the loan is
proposed to be repaid. (Not exceeding 48
according to Rules 46) ________________________________
7. ^èþ§é §éÆæÿ ´÷§óþ Ððþèþ¢Ðèþ ¯ðþËçÜÇ ièþÐèþ
Total monthly emoluments drawn by the subscriber ________________________________
8. Ðóþèþ¯èþÐèþ ¯èþyìþ èþWYç³Ë
Deductions from pay ________________________________
(G) B.Éç³.Éç³.i.Á. ÔéQ Éï³ÑÄèÿÐèþ
A.P.G.L.I. Dept. Premum ________________________________
(¼) B.Éç³.Éç³.i.Á.ÔéQ º}ýÐèþ ÐéÆÿ§é
A.P.L.I.D. Loan instalment ________________________________
(íÜ) H§æþÆÿ¯é CèþÆæÿ çÜçßMéÆæÿ çÜZÐèþ ÌôýMæü çÜZÐèþË ÐéÆÿ§é Ððþèþ¢
Instalments of any other Co-operative Society a Societies ________________________________
(yìþ) »êÅN º}ýÐèþ
Bank Loans ________________________________
(C) Éç³¿æýèþÓÐèþ ÐèþlÆæÿ ^óþíÜ¯èþ ÐðþsêÆæÿ MéÆæÿ º}ýÐèþ ÌôýMæü Væüçß °ÆéÃ}ýÐèþË
Motor Car Loan or House Building Loan sanctioned by Government ________________________________
(G·) B§éÄèÿç³ ç³¯èþ²
Income Tax ________________________________
(h) HÐèþÆÿ¯é CèþÆæÿ èþWYç³Ë
Any other deductions ________________________________
Ððþèþ¢Ðèþ
Total ________________________________
9. º}ýÐèþ ^ðþÍÏ^èþ MøÆæÿ ÉsóüfÈ ÌôýMæü õÜtr »êÅN É»ê_ õ³Ææÿ
The name of the Treasury or branch of the State Bank
where the payment of loan is desired. ________________________________
10. _Ææÿ¯éÐèþ
Address ________________________________
ò³¯èþ ñþÍí³¯èþ ÑÐèþÆæÿÐèþË, fèþ ç³Ææÿ^èþºyìþ¯èþ §æþÆæÿRêçÜ¢Ìø ñþÍí³¯èþ ÑçÙÄèÿÐèþË çÜÇÄðÿ¯èþÐèþ°Äèÿ ò³ ñþÍí³¯èþ AÐèþçÜÆæÿÐèþ ÌôýMæü A¯èþÐèþçÜÆæÿÐèþË
°Ñèþ¢Ðèþ ÐèþÉèþÐóþ ò³MæüÐèþ¯èþ QÆæÿa ^óþÄèÿVæüË¯èþ°Äèÿ C§æþ ÐèþËÐèþ¯èþ Éç³Mæüsìü^èþ^èþ¯é²¯èþ. ÔéQ °ÄèÿÐèþÐèþã ¯èþ¯èþçÜÇ_ BÉ«æþÉç³§óþÔý Éç³¿æýèþÓ
ÁÐèþ ÔéQ MéÆæÿÅ§æþÇØMìü °Ææÿ~Æÿ^èþ ç³§æþ®èþË¯èþ, Ðóþèþ¯èþÐèþ ¯èþ_ º}ýÐèþ, Ðèþyìþz èþXYç³Ë¯èþ ^óþÄèÿ Eèþ¢ÆæÿÓË gêÈ ^óþÄèÿrN C§æþ ÐèþËÐèþVé
ÐéÇMìü A¬MéÆæÿÐèþ C^èþa^èþ¯é²¯èþ.
I hereby declare that the particulars stated above as well as those mentioned in the covering application are
correct and that I shall spend the amount received only on the object or objects, mentioned above. I hereby
authorise the Director Directarate of Insurance Department Government of Andhra Pradesh to pass orders to effect
recoveries of Loan and interest from my salary in the manner as may be prescribed by him in accordance with the
rules of the Department.
ôþ¨ : §æþÆæÿRêçÜ¢ §éÆæÿ çÜèþMæüÐèþ ÌôýMæü »ö^èþ¯èþ ÉÐóþÍ ÐèþÉ§æþ

Date ....... 197 Signature of Thumb Impression of the applicant
ò³ §æþÆæÿRêçÜ¢Ìø ñþÍí³¯èþ ÑÐèþÆæÿÐèþË ¯éN ñþÍíÜ¯èþèþ ÐóþÆæÿN ¯óþ¯èþ ÑÔèýÓíÜ^èþ¯èþèþ ÐèþÆæÿN Äèÿ§éÆæÿ¦ÐèþË°Äèÿ, ò³ çÜèþMæüÐèþ ÌôýMæü »ör¯èþ
ÉÐóþÍ ÐèþÉ§æþ ...................................................... VéÇ §æþ°Äèÿ C§æþ ÐèþËÐèþVé «æþÒMæüÇ^èþyæþÐðþ¯èþ¨. BÄèÿ¯èþ B.Éç³.Éç³.i.Á.
ÔéQ ¯èþyìþ Ææÿ. .................................... º}ýÐèþ ¡çÜMö° Äèÿ¯é²Ææÿ. C§æþË CMæü¯èþ Ææÿ. ....................................
Ë »êMîü Äèÿ¯é²Ææÿ.
It is hereby certified that the particulars stated in the above application are correct to the best of my knowl-
edge and belief and that the above signature or thumb/impression is of Shri ...........................................................
He ad obtained a loan of Rs. ........................... from A.P.G.I. Dept. out of which Rs. ..................... are still out-
standing.
«æþÒMæüÇ^èþ Vóühsðütyþ A¬MéÇ çÜèþMæüÐèþ

Signature of the
certifying Gazetted Officer ___________________
ôþ¨: «æþÒMæüÇ^èþ A¬MéÇ õ³Ææÿ

Date ... 197 Name of the certifying Officer _________________
MéÆéÅËÄèÿÐèþ ÐèþÉ§æþ çßø§é

Office Seal Designation _______________________________
VæüÐèþ°Mæü:& §æþÆæÿRêçÜ¢ §éÆæÿ C¨ÐèþÆæÿMóü ÁÐèþ ÔéQ ¯èþyìþ º}ýÐèþ ¡çÜN¯èþ² ÄðÿyæþË ò³ «æþÐèþ ç³ÉèþÐèþò³ §æþÆæÿRêçÜ¢ §éÆæÿ°, AÐèþÅÐèþíßèþ E¯èþ²ø§øÅW
çÜèþMæüÐèþ ^óþÄèÿÐèþÌñý¯èþ.
Note:- In case the applicant has already obtained loan from Insurance the above certificate should be signed by
the applicant's immediate superior.
ç³¨ ò³çÜË Ýëtç³
Stamp 20 P. B.Éç³.Éç³.Á.Mé.{îþ.¯ðþ.40
DIR. OF INS. F. NO.40
ÆæÿÖ§æþ
RECEIPT
VæüÐèþ°Mæü:& Ððþèþ¢Ðèþ Ææÿ. 20 ËN Ñ_¯èþ GyæþË Ýëtç³ Asìü^èþÐèþÌñý¯èþ.
Note:- If the amount exceeds Rs. 20, this receipt should be duly stamped.
×/×Ðèþ ...................................................................... VéÇ ÁÐèþ / É´ëÑyðþr ç·yæþ/º}ýÐèþ/

»ø¯èþçÜ Ððþèþ¢Ðèþ¯èþN çÜº¨_¯èþ ^èþ§é§éÆæÿ ¯ðþºÆæÿ ................................... ÆæÿÖ§æþ .................................. AÆÿ¯èþ
¯ó þ ¯è þ C§æ þ Ðè þ ËÐè þ Vé BÉ«æ þ Éç ³ §ó þ Ô ý Éç ³ ¿æ ý è þ Ó ÁÐè þ MéÆéÅËÄè ÿ Ðè þ , ò ß § æ þ Æé»ê§æ þ ¯è þ yì þ Ææ ÿ ´ëÄè ÿ Ë (AMð ü ËÌø)
................................... (AæþÆæÿÐèþËÌø) .................................................................. çÜÓÄèÿÐèþVé ×/
×Ðè þ .................................................................. §éÓÆé
................................................................. ôþ© VæüË .................................... ¯ðþºÆæÿ ^ðþNP & »êÅN
Éyéç·t §éÓÆé Ðèþsìüt¯èþrÏ ñþÍÄèÿç³Ææÿ^èþ^èþ¯é²¯èþ.
Receipt regarding the amount of Insurance / Provident Fund / Loan / Bonus of
Sri/Smt. .............................................................................. Subscriber No. ....................................................
I .............................................................................. hereby knowledge receipt of Rs. (in figures
......................................... ) (in words ........................................................................................................ ) From
the Directorate of Insurance, Hyderabad per self, Sri/Smt. ..............................................................................
Attorney/Bearer * per Cheque / B.D. No. ........................................ Dated ....................................... 19 .
¡çÜN¯èþ² ÐéÇ çÜèþMæüÐèþ ´ëËïÜ§éÆæÿ & MðüÏÆÿÐèþ§éÆæÿ ÄðÿMæüP çÜèþMæüÐèþ Ìôý§é »ör¯èþÉÐóþÍ ÐèþÉ§æþ
Signature of receipient Signature of thumb-Impression of the Policy holder/
Claiment.
[P.T.O.
¯é çÜÐèþæþÐèþÌø çÜèþMæüÐèþ ^óþíÜ¯èþ ò³ çÜèþMæüÐèþ & ÐóþÍ ÐèþÉ§æþ ____________________________ ÐéÇ É«æþÒMæüÆæÿ}ýÐèþ
×/×Ðèþ ...................................................... ç³ÆæÿçÜPÇ^èþMö° ò³ ^ðþNP¯èþ çÜÓÄèÿÐèþVé A§æþgôýÄèÿyæþÐðþ¯èþ¨.
On the strength of certification of
¯óþ¯èþ C§æþ ÐèþËÐèþVé «æþÐèþç³Ææÿ^èþ^èþ¯é²¯èþ.
______________________________________
I hereby certify that the above signature/thumb
_______________________________________________
impression is of Sri/Smt. ______________________ the above cheques reserved personally .
who has signed in my presence.
Væühsðüyæþ A¬MéÇ õ³Ææÿ

1. Name of the Gazetted Officer______________
___________________________________
___________________________________
çßø§é çÜç³Çsðüyðþr çÜàÄèÿ çÜ^éËNyæþ, ÁÐèþ

Superintendent Asst. Director of Insurance
2. Designation __________________________
«æþÒMæüÇ_¯èþ ôþ¨
3. Date of Attestation ______________________
MéÆéÅËÄèÿç³ ÐèþÉ§æþ
OFFICE SEAL
VæüÐèþÝë¢
Clerk
«æþÒMæüÇ_¯èþ A¬MéÇ çÜèþMæüÐèþ

Signature of the Certifying
Gazetted Officer
VæüÐèþ°Mæü:& BÉ«æþÉç³§óþÔý çÜÈÓçÜÌø Äèÿ¯èþ² Væühsðüyæþ A¬MéÇ^óþ Vé°, A¿æýÅÇ® ÆéÐèþ ÐðþËç³Ë °ÐèþíÜçÜ¢¯èþ²rÏÆÿ¯èþ^ø ÐóþhÉõÜtr^óþ ÆæÿÖ§æþ «æþ
Ðèþç³Ææÿ^èþÐèþÌñý¯èþ.
Note:- The receipt should be certified by a Gazetted Officer of Andhra Pradesh Government in Service or by a
Magistrate if the applicant is residing outside the State.

APGLI Loan Application

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B.Éç³.Éç³.i.Á.ÔéQ ¯ðþ.

É´ë¡Äèÿ ÁÐèþ yìþ³ç Åsìü yðþÆ ÿð MæüÆt ÿæ MéÆéÅËÄèÿÐèþ. ..............

ôþ¨ : §æþÆæÿRêçÜ¢ §éÆæÿ çÜèþMæüÐèþ ÌôýMæü »ö^èþ¯èþ ÉÐóþÍ ÐèþÉ§æþ

«æþÒMæüÇ^èþ Vóühsðütyþ A¬MéÇ çÜèþMæüÐèþ

ôþ¨: «æþÒMæüÇ^èþ A¬MéÇ õ³Ææÿ

MéÆéÅËÄèÿÐèþ ÐèþÉ§æþ çßø§é

×/×Ðèþ ...................................................................... VéÇ ÁÐèþ / É´ëÑyðþr ç·yæþ/º}ýÐèþ/

Sri/Smt. .............................................................................. Subscriber No. ....................................................

I .............................................................................. hereby knowledge receipt of Rs. (in figures

......................................... ) (in words ........................................................................................................ ) From

the Directorate of Insurance, Hyderabad per self, Sri/Smt. ..............................................................................

Attorney/Bearer * per Cheque / B.D. No. ........................................ Dated ....................................... 19 .

Væühsðüyæþ A¬MéÇ õ³Ææÿ

çßø§é çÜç³Çsðüyðþr çÜàÄèÿ çÜ^éËNyæþ, ÁÐèþ

«æþÒMæüÇ_¯èþ A¬MéÇ çÜèþMæüÐèþ

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APGLI Loan Application

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APGLI Loan Application

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Document Information

Original Description:

Copyright

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APGLI Loan Application

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B.Éç³.Éç³.i.Á.ÔéQ ¯ðþ.

É´ë¡Äèÿ ÁÐèþ yìþ³ç Åsìü yðþÆ ÿð MæüÆt ÿæ  MéÆéÅËÄèÿÐèþ. ..............

ôþ¨ : §æþÆæÿRêçÜ¢ §éÆæÿ çÜèþMæüÐèþ ÌôýMæü »ö^èþ¯èþ ÉÐóþÍ ÐèþÉ§æþ

«æþÒMæüÇ^èþ Vóühsðütyþ A¬MéÇ çÜèþMæüÐèþ

ôþ¨: «æþÒMæüÇ^èþ A¬MéÇ õ³Ææÿ

MéÆéÅËÄèÿÐèþ ÐèþÉ§æþ çßø§é

×/×Ðèþ ...................................................................... VéÇ ÁÐèþ / É´ëÑyðþr ç·yæþ/º}ýÐèþ/

Sri/Smt. .............................................................................. Subscriber No. ....................................................

I .............................................................................. hereby knowledge receipt of Rs. (in figures

......................................... ) (in words ........................................................................................................ ) From

the Directorate of Insurance, Hyderabad per self, Sri/Smt. ..............................................................................

Attorney/Bearer * per Cheque / B.D. No. ........................................ Dated ....................................... 19 .

Væühsðüyæþ A¬MéÇ õ³Ææÿ

çßø§é çÜç³Çsðüyðþr çÜàÄèÿ çÜ^éËNyæþ, ÁÐèþ

«æþÒMæüÇ_¯èþ A¬MéÇ çÜèþMæüÐèþ

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B.Éç³.Éç³.i.Á.ÔéQ ¯ðþ.

É´ë¡Äèÿ ÁÐèþ yìþ³ç Åsìü yðþÆ ÿð MæüÆt ÿæ MéÆéÅËÄèÿÐèþ. ..............

ôþ¨ : §æþÆæÿRêçÜ¢ §éÆæÿ çÜèþMæüÐèþ ÌôýMæü »ö^èþ¯èþ ÉÐóþÍ ÐèþÉ§æþ

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×/×Ðèþ ...................................................................... VéÇ ÁÐèþ / É´ëÑyðþr ç·yæþ/º}ýÐèþ/

Væühsðüyæþ A¬MéÇ õ³Ææÿ

çßø§é çÜç³Çsðüyðþr çÜàÄèÿ çÜ^éËNyæþ, ÁÐèþ

«æþÒMæüÇ_¯èþ A¬MéÇ çÜèþMæüÐèþ