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    Form Form No. 29 Inward No.: 8. Svwìá ® S ( R © Sli Òá R Xmso) Qsäìáv

    Uploaded by

    mass1984
    This document is a loan application form for an insurance policyholder. It collects details like name, date of birth, employment details, loan amount requested, repayment terms, bank account details for loan disbursal and recovery. Signatures of applicant and disbursing officer are also required.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Form Form No. 29 Inward No.: 8. Svwìá ® S ( R © Sli Òá R Xmso) Qsäìáv

    Uploaded by

    mass1984
    82 views3 pages
    This document is a loan application form for an insurance policyholder. It collects details like name, date of birth, employment details, loan amount requested, repayment terms, bank account details for loan disbursal and recovery. Signatures of applicant and disbursing officer are also required.

    Original Description:

    hi

    Original Title

    Loan Application

    Copyright

    © © All Rights Reserved

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    This document is a loan application form for an insurance policyholder. It collects details like name, date of birth, employment details, loan amount requested, repayment terms, bank account details for loan disbursal and recovery. Signatures of applicant and disbursing officer are also required.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    82 views3 pages

    Form Form No. 29 Inward No.: 8. Svwìá ® S ( R © Sli Òá R Xmso) Qsäìáv

    Uploaded by

    mass1984
    This document is a loan application form for an insurance policyholder. It collects details like name, date of birth, employment details, loan amount requested, repayment terms, bank account details for loan disbursal and recovery. Signatures of applicant and disbursing officer are also required.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    01/2014

    LOAN FORM

    VV RLRixqsV
    Form No. 29

    ssVWy sLi. 29

    Inward No.

    @LiRLS-sV sLi.
    APGLI

    Office Use Only

    NSLSRVxmso DxmsWgSLiR Li

    DIRECTORATE OF INSURANCE

    \lLiNRPlLi Amsn BsW=lLis=

    GOVERNMENT OF ANDHRA PRADESH

    ALiR xms[a`P xms VR*sVV, ALiR xms[a`P


    HYDERABAD, Andhra Pradesh

    \|RLS`

    District Insurance Office : __________

    dsW NSLSRVLi iM

    __________

    APPLICATION FOR LOAN

    VVsVV N]LRiNRPV RLRixqsV

    Policy No.

    Fy{qs sLi.
    1. Name of the Subscriber
    2.

    Fathers Name

    RLiyyLRiVs }msLRiV
    3. Designation x [y

    RLiT }msLRiV

    4. Date of Birth xmso s [j


    (As per Service Register)
    xqsLki*qs LjixtsQL`i xmsNSLRiLi

    D D M M Y

    5.

    Office where he is employed

    6.

    The Amount of Loan applied for

    7.

    D. D. O. Code

    D][gji xmss [RVVRVs NSLSRVLi }msLRiV

    T. T. J. N][`

    RLRixqsV [qx sVN]s VV sVVRL i

    The Number of Instalments in which the Loan is proposed to be repaid


    (Not exceeding 48, according to Rule 46)

    ( )

    12

    24

    36

    48

    VV sVVRL i Ljigji LiRRs xmsFyjR yLiVVy qx sLi (sRVsWs 46 xmsNSLRiLi 48 yLiVVyNRPV -sVLiRLSRV)
    8.
    9.

    Basic Pay

    Rmx so }qsV

    Gross Salary

    Total Deductions

    Net Salary

    RsVV sVVRL i

    sVVRL i Rgij LixmsoV

    sNRPLRi RLi

    10. Monthly Premium


    11.

    Pay Scale

    sVW s[R sLi

    sxqsLji {ms-sVRVsVV sVVRL i

    Name of the Bank where Payment of Loan is desired

    LRiV sVVR sVV Lixmso N][LiR VRVs LiN`P }msLRiV


    Branch Name

    Li }msLRiV

    IFS CODE

    H Fsmns RVqs N][`

    Bank Account No.

    LiNRPV y sLiLRiV
    (Contd 2)

    Visit Our Website : www.apgli.ap.gov.in

    :: 2 ::

    12.

    Employee I. D. No.

    D][gji HT sLiLRiV

    13.

    Aadhar Card No.

    AyL`i NSL`i sLiLRiV

    14.

    Mobile No.

    sVV\ sLiLRiV

    15.

    E Mail of Policyholder

    Fy{qsyLRiVs C c sVVLiVV

    16.

    Mobile No. of Drawing and

    AxLRi sVLjiRVV *R @jNSLji sVV\ sLiLRiV

    17.

    E Mail of Drawing and

    Disbursing Officer

    Disbursing Officer

    AxLRi sVLjiRVV *R @jNSLji C c sVVLiVV

    I hereby declare that the particulars stated above are true and correct.

    \|ms zmss -ssLSV, xqs\lLiss[ss LiVVLiRVsVWsVVgS RX-dsNRPLjiLiRVRVysV.


    I hereby authorise the Director of Insurance, Government of Andhra Pradesh to pass orders to
    effect recoveries of Loans and Interest from my salary in the manner as may be prescribed by him in
    accordance with the Rules of APGLI Fund.

    -sR dsW aS sRVsW xmsNSLRiLi, dsW aS \lLiNPR LRiV slLib[ PLis Lki[ sU][ FyV VV sVVys y RLi
    sVLiT Ljigji sxqsWV [}qsLiRV\ZNP RgRiV DRLRiV*V Lki [RVysNTP ALiR xms[a`P xms VR* dsW aS \lLiNPR LRiVNRPV @jNSLRi-sVxqsVysV.

    Date :

    Signature of Applicant

    [j iM

    RLRixqsVyLRiVs xqsLiRNRPsVV

    It is certified that the particulars stated in the above application are correct to the best of my
    knowledge and belief and the above Signature of Sri ___________________ is signed in my presence. He
    obtained a Loan of
    _______________ from APGLID out of which
    ______________ is still
    outstanding.

    \|ms RLRixqsV[ zmss -ssLSV yNRPV zqssLiRsLRiNRPV sVLjiRVV -saRP*bPLis s[VLRiNRPV xqs\lLiss[ss LiVVLiRVsVWsVVgS
    RX-dsNRPLjiLiRVRVysV. $ ___________________ \|ms RLRixqsV \|ms xqsLiRNRPsVV y xqssVORPQsVV[ [aSLRiV. CRVs dsW aS sVLiT
    gRiRLi[[
    ___________________ LRiVsVV F~LijsoyLRiV. C sVVR sVV sVLiT
    ___________________ LiVVLiNS
    LiRszqssosj.
    Signature of Drawing and Disbursing
    Officer with Seal
    Station :

    xqssVV iM
    Date :

    [j iM

    AxLRi sVLjiRVV *R @jNSLji xqsLiRNRPsVV


    NSLSRV sVVR][
    Name :
    (In Block Letters)

    }msLRiV iM
    (Contd 3)
    Visit Our Website : www.apgli.ap.gov.in

    :: 3 ::
    1/-

    Revenue Stamp

    lLissW ryLims
    STAMP RECEIPT

    LRibdPRV

    Note : If the Amount exceeds

    gRisVsNRP iM \|msNRPLi

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

    5,000/c NRPV -sVLisLiVV[ ryLixmso @NTPLiy

    Policy No. ___________


    Fy{qs sLiLRiV iM ___________

    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.

    $ / $sV ______________________ @sV s[sV -sR dsW aS \lLiNPR lLi[V, \|RLSRV yLji sVLiT
    ________________ (LRiWFyRVV __________________________________________________________
    sWRs[V) [j iM ______________________ sLiLRiV ______________________ gRi NRPV / T. T. / As \s }mssVLi
    y*LS @LiRVN]sV BLiRVsVWsVVgS LRibdPRV @LiR[qx sVysV.
    Signature

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

    $ / $sV _____________________________________ [zqss \|ms xqsLiRNRPsVV y xqssVORPQsVV[ [aSLRis


    RX-dsNRPLjiLiRVRVysV.
    Station :

    xqssVV iM

    Signature of Drawing and Disbursing


    Officer with Seal

    AxLRi sVLjiRVV *R @jNSLji xqsLiRNRPsVV


    NSLSRV sVVR][
    Date :

    [j iM

    Name :

    }msLRiV iM

    Designation :

    x[y iM

    Visit Our Website : www.apgli.ap.gov.in

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