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DATA FOR THE APGLI PROPOSAL FORM
(ALL THE FIELDS SHOULD BE FILLED IN CAPITAL LETTERS ONLY)
for details contact cell : 9440297273, Ch Nagendra Rao, SA(Maths), SRRZPHS Nuzvid.
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1District insurance officeVIJAYAWADA
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2POLICY TYPEENHANCEDPolicy No (If new policy, leave it as blank)L804000
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3Name of the Subscriber (SUR NAME FIRST)CHIXXX NAXXXXXXXXX
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4Father's Name SAXXXXXXXXX
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5MALE/FEMALEMALE
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6Marital StatusMarried
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If married, No of children and their ageNo of children 2age1719
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7DesignationSCHOOL ASSISTANT
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8Date of Birth15-01-1972
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9Date of First Appointment15-06-1995
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Office where he is employed
SRRZPH SCHOOL NUZVID
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11MandalNUZVID MANDAL
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12DistrictKRISHNA DISTRICT
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13PIN Number of village521XXX
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14DDO Code051XXXXXXXX
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15Majar Head2202
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16Employee I. D. No.054XXXX
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17Basic Pay (Rs.)43680
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18Pay Scale54060-140540
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19Aadhar Card No867449859046
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20Mobile No. 944XXXXXXX
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21E – Mail of Policyholder nagendraxxxxxx@gmail.com
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22Are you in Good Health YES
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23a) Have you in the preceeding (3) years been absent on Leave on Medical Grounds for more than (10) days at a time ?NO
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b) If Yes, give details
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24Have you ever suffered from any of DiseasesHeart Ailment NOKidney NO
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CancerNOLungsNO
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 If Yes, give details of Disease, duration and If Yes, give details of Disease, duration and Treatment received
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25 Are you a physically challenged person.NO
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26 If already insured, Total old Premium (Rs.)600Proposed Monthly Premium (Rs.)800
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27Month and Year of Recovery MonthOctoberYear2022
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Token No and Date Token No1254Date10/25/2022
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27DETAILS OF NOMINATION
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S. NoName of NomineeName of Nominee’s FatherAgeRelationship of NomineeShare (%)
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1CH SAI PHANINDRANAGENDRA RAO19SON50%
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2CH SAI MANISHNAGENDRA RAO17SON50%
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3%
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4%
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5%
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6%
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43
44
45
46
47
48
49
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51
52
53
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56
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60
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98
182
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