FORM NO.

1-A
ANNEXURE
DIRECTORATE OF INSURANCE
GOVERNMENT OF ANDHRA PRADESH:: HYDERABAD-1

POLICY NO. REGIONAL OFFICE

PROPOSAL No.

PROPOSAL FOR FURTHER INSURANCE

(PLEASE ANSWER THE QUESTIONS FULLY AND DISTINCTLY)

1 Name in full (Block Letters): Female / Male :

2 Father’s Name in full : Address :-

Designation :

Date of Birth :

3 Are you Married :

If married mention :

i)    No. of children Living and their present ages : Age:

ii)  No. of childrens dead with ages & year of death : NIL

24 Details of Service in State Government :

a)   Date of First Appointment:

b)   Present/Substantive post held if any: Pay Scale

24 If already insured with

a) DIRECTORATE OF INSURANCE: POLICY NO. / MONTHLY
NOS. PREMIUM
1)
2)
3)
24)
a) to be filled after verifying policy documents
b)  Proposed monthly premium Rs.
(deducted from the Salary Challan remitted)

24 a) Mention the date as on which the previous

assurance was issued:

b) Are you in good health? Yes

c) a) Has you health been effected since the :

date of mentioned at (a) is so, give full
particulars of the illness and treatment No.
and treatment undergone alongwith
pies of medical certificate if any.

(b) Give particulars of leave applied for if any : No

on Medical Grounds, if none, state ‘NIL'

(c) Have there been any serious illness or death :

among the members of your family since No
the date mentioned in answer to (a) above?
Give details if any.
 (FOR FEMALES ONLY)

24 Have your periods been regular

and painless and are they so now?

24 State the last date of your last menstruation:

NIL
24 When was your last confinement?

24 Are you pregnant now?

24 Have you had any miscarriages?

24 Details of Nominations :-
a) Name of the Nominee/Nominees :
b) Name of Nominee’s Father :
c) Relationship of Nominee to the proponent :
d) Present age of the Nominee/Nominees :
e) Share/Shares :

I do hereby declare that the above answers and particulars are correct and true
that I have not withheld any information for an assurance on my life.

Date: Signature of the person whose :

Life is proposed to be assured.

CERTIFIED BY THE OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED

I certify that the service particulars and

other particulars stated above are correct and the proposer is now on leave at the time of declaration
and th

R in all Rs. from the pay of Sri

s._
vide token No 15 to 20(20) dated ### and cheque No:
___
of
___A.P.A.O., T.G.P., Nellore
___
Dated
__ Signature:
Station:
in
all Designation:
Rs.
___ OFFICE SEAL
___
N.B.
___ – NOMINATION IS COMPULSORY.
___
_
fro
m
the
pa
y
of
___
___
___
___
___
_
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tok
APGLI FORM

1 V.Bhaktavathsalam Male Typist 10/28/1963

2 M.V.Ramana Kumar Male Sr.Asst. 4/11/1960
3 B.Vijaya Daniel Male Sr.Asst. 1/14/1973
4 G.Udaya Bhaskar Male Sr.Asst. 8/15/1969
5 G.Jaya Ramaiah Male Sr.Asst. 7/1/1961
6 SK.Kalesha Vali Male Jr.Asst. 7/14/1967
7 P.V.C.Madhusudhana PrasadMale Jr.Asst. 5/18/1975
8 N.Prabhakar Singh Male Jr.Asst. 8/12/1967
9 M.Srinivasulu Male Jr.Asst. 1/10/1966
10 G.Ramesh Babu Male Typist 7/1/1973
11 Ch.Ramanamma Female Typist 2/7/1971
12 A.Subba Rao Male Typist 8/15/1975
13 D.Subrahmanayam Male Jr.Steno 7/1/1967
14 O.Sarada Female A.E.E.
15 N.V.L.P. Ramana Rao Male A.E.E. 6/10/1973
16 D.V.N. Siva Prakash Male A.E.E.
17 G.Sivarama Murthy Male Jr.Tech.officer 8/14/1967
18 A.V.S. Prasad Male Tech.Asst. 10/15/1959
19 Ch.V.Subbamma Female Attender
20 T.Manju Kumar Male Attender 8/19/1975
21 N. Rohini Prasad Male Attender 10/5/1968
22 Md. Nazeemunisa Begum Female Attender
23 K.Ramaiah
 Nio.of children ages
Father's name office
V.Venkateswarlu S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta,
13 Yrs 11Nellore.524003
Yrs NIL
M.V.Krishna Murthy S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta,
18 yrs 14Nellore.524003
yrs NIL
B.Anandaiah S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta,
4 Yrs 2 Nellore.524003
Yrs. NIL
G.Haanath Babu S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta,
11 yrs 10Nellore.524003
yrs NIL
G.Ramachandraiah S.S.L.C. &
Married
S.B.Circle Office,
1 Dargamitta,
9 yrs. Nellore.524003
NIL
Late SK.Galishaid S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta,
11 yrs 8 Nellore.524003
yrs NIL
P.Subbarayudu S.S.L.C. &
Married
S.B.Circle Office,
1 Dargamitta,
3 Months Nellore.524003
NIL
N.Bala Bharath Singh S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta, Nellore.524003
NIL
M.V.Ramanaiah S.S.L.C. &
Married
S.B.Circle Office,
1 Dargamitta,
5 yrs Nellore.524003
NIL
G.Hazarathaiah S.S.L.C. &
Married
S.B.Circle Office,
1 Dargamitta,
3 yrs Nellore.524003
NIL
Ch.Siddi Raju S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta,
11 yrs 8yrs
Nellore.524003
NIL
A.Veeraiah S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta,
8 yrs 5 Nellore.524003
yrs NIL
D.Venkata Subba Raju S.S.L.C. &
Un-married
S.B.Circle Office,
--- Dargamitta, Nellore.524003
NIL
O.Anjaneyulu S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta,
10 yrs. 8 Nellore.524003
yrs NIL
N.B.C.Mohan Rao S.S.L.C. &
Married
S.B.Circle Office,
1 Dargamitta,
6 yrs Nellore.524003
NIL
S.S.L.C. &
Married
S.B.Circle Office, Dargamitta, Nellore.524003
NIL
G.Radhakrishnaiah S.S.L.C. &
Married
S.B.Circle Office,
1 Dargamitta,
9 yrs. Nellore.524003
NIL
A.Subba Rao S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta,
21 yrs 19Nellore.524003
yrs NIL
S.S.L.C. &
Married
S.B.Circle Office,
--- Dargamitta, Nellore.524003
NIL
Late. T.Samel S.S.L.C. &
Married
S.B.Circle Office,
--- Dargamitta, Nellore.524003
NIL
N Krishnaiah S.S.L.C. &
Married
S.B.Circle Office,
2 Dargamitta,
11 Yrs 9 Nellore.524003
Yrs NIL
S.S.L.C. &
Married
S.B.Circle Office, Dargamitta, Nellore.524003
NIL
 Policy No. Present Total
Typist 6845 5200-11715 493194 - A 75 250
Sr.Asst. 10845 6505-14665 438234 - ABC 125 450
Sr.Asst. 8170 6195-13945 475929 AB 75 350
Sr.Asst. 8385 6195-13945 475902-A 75 350
Sr.Asst. 8385 6195-13945 476731 - A 75 350
Jr.Asst. 6675 5200-11715 2001403 - A 75 250
Jr.Asst. 6675 5200-11715 2001306 - A 75 250
Jr.Asst. 7200 5200-11715 493548 - A 75 250
Jr.Asst. 7770 5200-11715 462104 -ABC 100 350
Typist 6350 5200-11715 2001919 - AB 75 250
Typist 6505 5200-11715 700418 - A 75 250
Typist 4950 4825-10845 2001304 -A 50 200
Jr.Steno 6505 5200-11715 2001918 - AB 75 250
A.E.E., 11715 10285-21835 2004962 - A 150 450
A.E.E. 9775 9285-19775 2002867 - A 150 350
A.E.E. 9520 9285-19775 New case 75 350
Jr.Tech.Officer 8600 5470-12325 471072 ABC 100 350
Tech.Asst. 8385 5200-11715 428243 - A 100 350
Attender 7015 4260-9520 448910 -AB 75 250
Attender 5075 3850-8815 2001305 - A 50 200
Attender 4825 3850-8815 2003136 -AB 50 200
Attender 4480 3850-8815 2003165 - A 100 150
New case
proposedAssurance given dateDate of first appointment are you good
C(A)(B)(C)
health
175 10/14/1997 11/24/1994 Yes No.
325 12/27/2005 11/7/1981 Yes No.
275 0 3/31/1991 Yes No.
275 0 12/6/1990 Yes No.
275 0 11/30/1990 Yes No.
175 0 6/8/1995 Yes No.
175 0 9/29/1995 Yes No.
175 0 2/26/1993 Yes No.
250 0 12/2/1987 Yes No.
175 10/12/2000 7/29/1997 Yes No.
175 0 3/14/1996 Yes No.
150 0 3/28/1996 Yes No.
175 10/12/2000 3/11/1996 Yes No.
300 0 1/22/1996 Yes No.
200 0 11/3/1999 Yes No.
275 0 Yes No.
250 4/8/2003 11/29/1990 Yes No.
250 0 8/1/1979 Yes No.
175 0 Yes No.
150 0 7/11/1994 Yes No.
150 --- 5/20/1996 Yes No.
50 Yes No.
C(A)(B)(C) 7 8 9 10 11 Name of the Nominee
No No --- --- --- --- --- V.Chandra Kala
No No --- --- --- --- --- M.Padma Prasuna
No No --- --- --- --- --- B.Sirisha
No No --- --- --- --- --- G.Meena Kumari
No No --- --- --- --- --- K.Bharathi
No No --- --- --- --- --- SK. Asia Parveen
No No --- --- --- --- --- P.Manju Bhargavi
No No --- --- --- --- --- N.Padma Gowri Bai
No No --- --- --- --- --- M.Padmavathi
No No --- --- --- --- --- G.Suvarna
No No --- --- --- --- --- N.Srinivasulu
No No --- --- --- --- --- A. Hymavathi
No No --- --- --- --- --- D.Venkata Subba Raju
No No --- --- --- --- --- M.Nagaraju
No No --- --- --- --- --- D.V.S.K. Jyothsna
No No --- --- --- --- ---
No No --- --- --- --- --- G.Sandhya Rani
No No --- --- --- --- --- A.Sujatha
No No --- --- --- --- ---
No No --- --- --- --- --- T.Sumalatha
No No --- --- --- --- --- N Vijitha
No No --- --- --- --- ---
K.Anjaneya Sarma Wife
C.Lakshmikantham wife
A.Devadanam wife
G.Subrahmanayam wife
K. Sarveswaraiah Wife
Late. B.Ghouse wife
Sreerama Murthy wife
M. Balaji Singh Wife
M.Ramanaiah Wife
Late G.Raghavaiah wife
N.Pullam Raju Husband
N.Ramanaiah Wife
D.Venkata Raju Father
M.Subrahmanayam Husband
D.Veera Sekhar Wife

Late. V.Sreerama Sarma Wife

S.Ramanaiah wife

D.Mohan Rao Wife

I Balakrishnaiah Wife
38 yrs. Full
37 Yrs. Full
28 Yrs. Full
32 yrs. Full
41 yrs. Full
35 yrs Full
22 yrs Full
28 Yrs. Full
30 Yrs. Full
33 yrs. Full
40 yrs Full
28 Yrs. Full
80 yrs Full
45 yrs Full
29 yrs Full
Full
32 yrs. Full
44 yrs Full
Full
22 yrs Full
32 Yrs. Full
Full
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
048130, Dt.31/12/2005 for Rs.391960/- 15 to 20(20) 12/31/2005 9317.00
From To
Sri C.Rajagopal Reddy, B.E., The Asst.Director,.
Superintending Engineer, A.P.Govt. Life Insurance,
S.S.L.C. & S.B.Circle, Nellore.
Nellore.

Letter No. SE/SSLC& SBC/NLR/AB/S1/EC.4/ Dt. /01/2006

Sir
Sub: A.P.G.L.I. - Revision of A.P.G.L.I. Subscriptions in R.P.S. 2005 -
Proposals for "Additional Insurance" - forwarded - Regarding.

Ref: G.O. Ms. No. Dt.

….
In terms of the Govt. Orders under reference cited, the monthly
subscription to A.P.G.L.I of the following employees working in the S.S.L.C. &
S.B.Circle Office, Nellore whose age is below 48 years is enhanced as per the
limits given in the above G.O. and recovered from their pay bill for 12/2005. The
proposals in the prescribed proforma obtained from them for " Additional
Insurance " is hereby forwarded for issue of necessary bonds at an early date.

S/Sri
1 M.V.R.Kumar Sr.Asst.
2 B.Vijaya Daniel Sr.Asst.
3 G.Udaya Bhaskar Sr.Asst.
4 G.Jaya Ramaiah Sr.Asst.
5 SK.Kalesha Vali Jr.Asst.
6 P.V.C.Madhusudhana Prasad Jr.Asst.
7 N.Prabhakar Singh Jr.Asst.
8 M.Srinivasulu Jr.Asst.
9 V.Bhaktavathsalam Typist
10 G.Ramesh Babu Typist
11 Ch.Ramanamma Typist
12 A.Subba Rao Typist
13 D.Subrahmanayam Jr.Steno
14 O.Sarada A.E.E.
15 N.V.L.P. Ramana Rao A.E.E.
16 D.V.N. Siva Prakash A.E.E.
17 G.Sivarama Murthy D.M.Gr.III
18 A.V.S. Prasad Tracer
19 Ch.V.Subbamma Attender
20 T.Manju Kumar Attender
21 N. Rohini Prasad Attender
22 Md. Nazeemunisa Begum Attender
23 K.Ramaiah ( first proposal form) Attender

Encl:- 23 Nos. proposals in original Yours faithfully,

as received.
C.Rajagopal Reddy,
//t,c,f.b.o// Superintending Engineer,
SSLC & SB.Circle, Nellore.

Superintedent
 up

/01/2006

Engineer,
e, Nellore.
 FORM NO.1-A
ANNEXURE
DIRECTORATE OF INSURANCE
GOVERNMENT OF ANDHRA PRADESH:: HYDERABAD-1

POLICY NO. REGIONAL OFFICE

PROPOSAL No.

PROPOSAL FOR FURTHER INSURANCE

(PLEASE ANSWER THE QUESTIONS FULLY AND DISTINCTLY)

1 Name in full (Block Letters): N. Rohini Prasad Female / Male : Male

2 Father’s Name in full : N Krishnaiah Address :-

S.S.L.C. & S.B.Circle Office,
Designation : Attender Dargamitta,
Nellore.524003
Date of Birth : 10/5/1968

3 Are you Married : Yes

If married mention :

i)   No. of children Living and their present ages : 2 No. Age: 11 Yrs 9 Yrs

ii)  No. of childrens dead with ages & year of death : NIL

4 Details of Service in State Government :

a)   Date of First Appointment: 5/20/1996

b)   Present/Substantive post held if any: Pay Scale
4825 3850-8815
5 If already insured with
a) DIRECTORATE OF INSURANCE: POLICY NO. / MONTHLY
NOS. PREMIUM
1) 2003136 -AB 50.00
2)
3)
4)
a) to be filled after verifying policy documents
b) Proposed monthly premium Rs. 150.00
(deducted from the Salary Challan remitted)

6 a) Mention the date as on which the previous ---

assurance was issued:

b) Are you in good health? Yes

c) (a) Has you health been effected since the :

date of mentioned at (a) is so, give full
particulars of the illness and treatment No.
and treatment undergone alongwith
copies of medical certificate if any.

(b) Give particulars of leave applied for if any : No

on Medical Grounds, if none, state 'NIL'

(c) Have there been any serious illness or death :

among the members of your family since No
 the date mentioned in answer to (a) above?
Give details if any.

(FOR FEMALES ONLY)

7 Have your periods been regular

and painless and are they so now?

8 State the last date of your last menstruation:

NIL
9 When was your last confinement?

10 Are you pregnant now?

11 Have you had any miscarriages?

12 Details of Nominations:
a) Name of the Nominee/Nominees : N Vijitha
b) Name of Nominee’s Father : I Balakrishnaiah
c) Relationship of Nominee to the proponent : Wife
d) Present age of the Nominee/Nominees : 32 Yrs.
e) Share/Shares : Full

I do hereby declare that the above answers and particulars are correct and true
that I have not withheld any information for an assurance on my life.

Date: Signature of the person whose :

Life is proposed to be assured.

CERTIFIED BY THE OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED

I certify that the service particulars and other particulars stated above are correct and the
proposer is now on leave at the time of declaration and the proponent’s signature has been a fixed in my
presence. The first premium for further insurance is recovered at

R 150.00 in all Rs. 9317.00 from the pay of Sri N. Rohini Prasad
s._
vide token No 15 to 20(20) dated ### and cheque No: 048130, Dt.31/12/2005 for Rs.391960/-
___
of
___A.P.A.O., T.G.P., Nellore
___
Station :
__ Signature:
in
all
Date : Designation:
Rs.
___
___ OFFICE SEAL
___
___
_
N.B. – NOMINATION IS COMPULSORY.
fro
m
the
pa
y
of
___
___
___
 FORM NO.1-A
ANNEXURE
DIRECTORATE OF INSURANCE
GOVERNMENT OF ANDHRA PRADESH:: HYDERABAD-1

POLICY NO. REGIONAL OFFICE

PROPOSAL No.

PROPOSAL FOR FURTHER INSURANCE

(PLEASE ANSWER THE QUESTIONS FULLY AND DISTINCTLY)

1 Name in full (Block Letters): M.Muralikrishna Female / Male : Male

2 Father’s Name in full : M. Srinivasulu Address :-

Executive Engineer,
Designation : Asst Execuitve Engineer S.S.L.C. & S.B. Division
No.2,
Date of Birth : 7/1/1976 Nellore.

3 Are you Married : Yes

If married mention :

i)   No. of children Living and their present ages : 2 No. Age: 5 Yrs 2 Yrs

ii)  No. of childrens dead with ages & year of death : NIL

4 Details of Service in State Government :

a)   Date of First Appointment: 11/4/2003

b)   Present/Substantive post held if any: Pay Scale
9285 9285-20550
5 If already insured with
a) DIRECTORATE OF INSURANCE: POLICY NO. / MONTHLY
NOS. PREMIUM
1) 200.00
2)
3)
4)
a) to be filled after verifying policy documents
b) Proposed monthly premium Rs. 150.00
(deducted from the Salary Challan remitted)

6 a) Mention the date as on which the previous ---

assurance was issued:

b) Are you in good health? Yes

c) (a) Has you health been effected since the :

date of mentioned at (a) is so, give full
particulars of the illness and treatment No.
and treatment undergone alongwith
copies of medical certificate if any.

(b) Give particulars of leave applied for if any : No

on Medical Grounds, if none, state 'NIL'

(c) Have there been any serious illness or death :

among the members of your family since No
 the date mentioned in answer to (a) above?
Give details if any.

(FOR FEMALES ONLY)

7 Have your periods been regular

and painless and are they so now?

8 State the last date of your last menstruation:

NIL
9 When was your last confinement?

10 Are you pregnant now?

11 Have you had any miscarriages?

12 Details of Nominations:
a) Name of the Nominee/Nominees : M. Jyothsna
b) Name of Nominee’s Father : Ch V Sesha Reddy
c) Relationship of Nominee to the proponent : Wife
d) Present age of the Nominee/Nominees : 27 Yrs.
e) Share/Shares : Full

I do hereby declare that the above answers and particulars are correct and true
that I have not withheld any information for an assurance on my life.

Date: Signature of the person whose :

Life is proposed to be assured.

CERTIFIED BY THE OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED

I certify that the service particulars and other particulars stated above are correct and the
proposer is now on leave at the time of declaration and the proponent’s signature has been a fixed in my
presence. The first premium for further insurance is recovered at

R 150.00 in all Rs. from the pay of Sri M.Muralikrishna

s._
vide token No dated and cheque No:
___
of
___A.P.A.O., T.G.P., Nellore
___
Station :
__ Signature:
in
all
Date : Designation:
Rs.
___
___ OFFICE SEAL
___
___
_
N.B. – NOMINATION IS COMPULSORY.
fro
m
the
pa
y
of
___
___
___