GCP-J.No. 74-27-9-2022-50,000.

APLICATION FOR POLICY

bÕ\d” <äs¡U≤düTÔ

TSGLI Form No. 1

bòÕs¡+ HÓ+. 1

DIRECTORATE OF INSURANCE
&Ó’¬sø£ºπs{Ÿ Ä|òt Çqü÷‡¬sHé‡
GOVERNMENT OF TELANGANA
‘Ó\+>±D Á|üuTÑÛ ‘·«eTT
HYDERABAD
ôV≤’ <äsêu≤<é
District Insurance Office : _______________

õ˝≤¢ ;e÷ ø±sê´\j·T+ : _______________

PROPOSAL FORM
Á|ü‹bÕ<äq |üÁ‘·eTT
All Columns Shall be filled in capitals only
nìï ø±\eTT\T ô|<ä› nø£ås¡eTT\‘√ |üP]Ô>± ì+|üe\j·TTqT
Policy No._________________________ Proposal Form No._________________________
bÕ\d” HÓ+.__________________________ Á|ü‹bÕ<äq HÓ+.________________________________
1. Name ù|s¡T
Surname Full Name |üP]Ô ù|s¡T 2. Sex Male / |ü⁄s¡Twüß&ÉT
Female / Ád”Ô

3. Father’s Name ‘·+Á&ç ù|s¡T 4. Designation ¨<ë

5. Employee Office Address ñ<√´– ø±sê´\j·T ∫s¡THêe÷ 6. Date of Birth|ü⁄{Ϻq ‘˚~

(As per Service Register) D D M M Y Y Y Y
düØ«dt ]õwüºsY Á|üø±s¡+

P I N
7. Date of First Appointment yÓTT<ä{Ï ìj·÷eTø£|⁄ü ‘˚~ D D MM Y Y Y Y

8. Marital Status $yêVæ≤‘·T˝≤ / n$yêVæ≤‘·T˝≤ / $‘·+‘·Tyê / $&Ü≈£î˝≤

Married UnMarried Widow Divorced

9. If Married No. of Children and their Ages |æ\¢\ dü+K´ ej·TdüT‡ (dü+.˝À)
$yêVæ≤‘·T˝…‘’ ˚ |æ\\¢ dü+K´ eT]j·TT yê] ej·TdüT´
10. Basic and Pay Scale eT÷\ y˚‘·qeTT eT]j·TT y˚‘·qeTT ùdÿ\T

11. DETAILS OF NOMINATION Hê$TH˚wqü T $esê\T

S.No. Name of Nominee Name of Nominee’s Father Age Relationship of Nominee Share
Áø£eT dü+K´ Hê$Tì ù|s¡T Hê$Tì jÓTTø£ÿ ‘·+Á&ç ù|s¡T ej·TdüT‡ #·+<ë<ës¡TìøÏ Hê$Tì‘√ dü+ã+<Ûä+ yê{≤

12. Are you in good Health Á|üdüTÔ‘·+ MT ns√>∑´+ u≤>∑T>± e⁄qï<ë [ ] Yes / ne⁄qT No / ø±<äT.
 :: 2::

13. Have you in the preceeding (3) years been absent on leave on Yes / ne⁄qT No / ø±<äT.
Medical Grounds for more than (10) days at a
time ? If Yes, give Details
>∑‘· eT÷&ÉT dü+e‘·‡sê\˝À MTs¡T yÓ’<ä´ ø±s¡D≤\ ô|’ ˇπøkÕ] (10) s√E\≈£î ô|’>±
ôd\e⁄ ô|’ ¬>’s¡TVü‰»s¡T nj·÷´sê? nsTT‘˚ Ä $esê\T ‘Ó\|ü+&ç.
14. 1. Have you ever suffered from any of the following Diseases :-
á ÁøÏ+~ ù|s=ÿqï yê´<ÛäT\˝À <˚ì‘√HÓ’Hê MTs¡T m|ü &Ó’Hê u≤<Ûä|ü&ܶsê ?
Heart Ailment >∑T+&Óyê´~Û Yes / ne⁄qT No / ø±<äT.

Kidney eT÷Á‘·|æ+&É+ Yes / ne⁄qT No / ø±<äT.

Cancer ø±´q‡sY Yes / ne⁄qT No / ø±<äT.

Lungs }|æ] ‹‘·TÔ\T Yes / ne⁄qT No / ø±<äT.

2. If Yes, give details of Disease duration and Treatment received

düe÷<ÛëqeTT Äe⁄qT nsTTq, yê´~Û $esê\T, ∫øχ rdüTø=ìq yÓ’<Ûä´ ùde\ $esê\T ‘Ó\Œ+&ç
15. Are you physically challenged person. If so, enclose Certificate issued by Yes / ne⁄qT No / ø±<äT.
a Competent Authority.
MT≈£î @<Ó’Hê XÊØs¡ø£ ˝À|ü+>±ì yÓ’ø£\´+>±ì ñqï≥¢sTT‘˚ n{Ϻ n+>∑yÓ’ø£\´+ $esê\T ‘Ó\|ü+&ç
yÓ’<ë´~Ûø±] C≤Ø #˚dæq n+>∑yÓ’ø£\´+ <Ûäèe|üÁ‘êìï düeT]Œ+#·+&ç.

16. If already Insured Policy No. Total Monthly Premium `

Ç~es¡πø ;e÷ #˚dæñqï#√ bÕ\d” HÓ+. HÓ\dü] Á|”$Tj·T+

17. Proposed Monthly Premium Á|ü‹bÕ~+∫q HÓ\dü] Á|”MTj·T+ `

18. Month and Year of Recovery ‘·–+Z |ü⁄ »]–q HÓ\ eT]j·TT dü+e‘·‡s¡+

19. Mobile No. yÓTTu…˝

’ Ÿ HÓ+.

20. Email Address ÇyÓTsTT˝Ÿ ∫s¡THêe÷ 21. Aadhar Card No. Ä<ÛësY ø±sY¶ HÓ+.

22. Employee ID No. ñ<√´– ◊&ç HÓ+ãs¡T

23. Major Head ô|<ä› |ü<äT› Try. D.D.O. Code Áf…»Ø &ç.&ç.z. ø√&é

Á|ü‹bÕ<ä≈£îì s¡÷&Ûç Á|üø£≥q

Declaration by the Proponent

ªÁ|üX¯ï\qT |üP]Ô>± ns¡ú+ #˚düT≈£îqï ‘·sê«‘· H˚qT ô|’q ‘Ó*|æq $es¡eTT\T Çe«&ÉeTsTT+~. n$ Hê dü«<ädü÷Ô]‘√ Áyêdæ+<Ó’qqT ø±ø£b˛sTTqqT Á|ü‹ n+X¯+
j·T<Ûës¡+ú düeTÁ>∑+, dü+|üPs¡+í nsTTqeìj·TT @ |ü]dæ‘ú T· \≈£î dü+ã+~Û+∫ H˚qT düe÷#ês¡eTT n+<ä#j
˚ T· e\dæjT· Tqï<√ Ä |ü]dæ‘ú T· \qT ì*|æyj
˚ T· ˝Ò<ìä j·TT ˝Ò<ë s¡V≤ü dü´+>±
e⁄+#·˝<Ò ìä j·TT H˚qT Ç+<äT eT÷\eTT>± Á|üø{£ +Ï #·T#·THêïqT. ô|’ $es¡D\T eT]j·TT á Á|üø≥£ q ;e÷ ø=s¡≈î£ Á|ü‹bÕ~+∫q ˇ|üŒ+<ëìøÏ ÁbÕ‹|ü~ø£\T>± e⁄+&Ü\ìj·TT
H˚qT ãT~Ûú|üPs¡«ø£+>±, @<Ó’Hê dü‘·´ <ä÷s¡yÓTÆq $es¡DqT #˚dæq≥T¢>±ì, ‘Ó*j·T|üs¡#·e\dæe⁄qï @<Ó’Hê |ü]dæú‹ì yÓ÷dü|ü⁄ ãT~ú‘√ <ë∫ e⁄+∫q≥T¢>±ì, Ç+<äTMT<ä≥
ø£qT>=qï jÓT&É\ dü<sä T¡ ø±+Á{≤≈£îº ÁøÏ+<ä #Ó*+¢ ∫j·TTqï Á|”$Tj·TeTT\ìï+{Ïì ø√˝ÀŒe˝…qìj·TT, Ä ˇ|üŒ+<ä+ dü+|üPs¡+í >± s¡<Tä › ø±e\qìj·TT H˚qT ˇ|ü ø=qT#·THêïqT.µ

Visit our website : www.tsgli.telangana.gov.in

 :: 3::
“ 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 circumstances with regard to which information has been required from me. I agree that
the foregoing statments 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 statment 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 becomes null and void ”

‘˚~ : J$‘· ;e÷ #˚j·T<ä\∫q e´øÏÔ dü+‘·ø£+ (‘˚~‘√ düVü‰)

Date : Proponent’s Signature with Date

Á|ü‹bÕ<äq ô|’ @ n~Ûø±] düeTø£å+˝À dü+‘·+ø£+ #˚j·Tã&çq<√ n n~Ûø±] <ÛäèMø£s¡D |üÁ‘·+

CERTIFIED BY OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED
ô|’q ù|s=ÿqï düØ«düT $esê\T dü]jÓÆTqy˚qìj·TT, Á|ü‹bÕ<ä≈£î&ÉT Hê düeTø£å+˝À dü+‘·+ø£+ #˚dæHê&Éìj·TT H˚qT <Ûäèe|üs¡TdüTÔHêqT. q÷‘·q / n<äq|ü⁄ ;e÷
ì$T‘·eÔ TT ‘·–+Z |ü⁄ #˚dqæ yÓTT<ä{Ï Á|”$Tj·T+ s¡÷. ````````````````````````eT]j·TT yÓTT‘·eÔ TT s¡÷.``````````````````````(Ç~ es¡π ø ‘·–+Z |ü⁄ #˚dqæ
eT]j·TT Á|üdüTÔ‘· Á|”$Tj·T+ ø£\T|ü⁄ø=ì)`````````````HÓ\ eT]j·TT`````````` dü+e‘·‡s¡eTT y˚‘·qeTT qT+&ç ‘˚~```````````````>∑\ {Àø£Hé
HÓ+ãs¡T`````````````````` <ë«sê edü÷\T #˚jT· &ÉeTsTTq~.

I Certify that the service particulars stated above are correct and proponent’s Signature has been affixed in my
presence. the First premium recoverd for fresh / subsequent Insurance is Rs. ______________________________in all
Rs. _______________(including previous and present Premium) from the pay of_________________ Month and
___________________year, vide token No. ____________________dated__________________

düú\eTT :
Station :
‘˚B‘√ ≈£L&çq dü+‘·ø£eTT
ÄVü≤s¡D eT]j·TT ã{≤«&É n~Ûø±]
‘˚~ : (d”«j·T <Ûèä Mø£sD¡ #Ó\<¢ Tä )Û
Date :

For OFFICE USE

O.R. ( )

Age at Entry Premium Sum Assured

T.I Rs. : Rs. :

A.I Rs. : Rs. : Signature with Date

Drawing and Disbursing Officer
Total Rs. : Rs. : (Self Attestation is not acceptable)
¨<ë :
As per TSGLI Fund Rule 5 Proposal has been scrutinised and O.R. Designation :
submitted for approval

ø±sê´\j·T eTTÁ<ä
Clerk Supdt. DIO Office Seal

Please Visit our website : www.tsgli.telangana.gov.in for Further information and guide lines
 GOOD HEALTH CERTIFICATE

This is to certify that Sri / Smt / Kum __________________

S/O / D/O W/O ______________________ working as ______________

in the Office of the _____________________________________

aged ( ) years, is found in good health without any ailments.

Date : Signature

Station :
Medical Officer / Civil Assistant Surgeon /
Deputy Civil Surgeon / Civil Surgeon
 NON – AVAILMENT OF LEAVE ON MEDICAL GROUNDS
CERTIFICATE

This is to certify that Sri / Smt / Kum _____________________

S/O / D/O / W/O ______________________ working as ______________

in the Office of the ________________________________ has not availed

any kind of Leave on Medical Grounds during the last three (3) Years.

Date : Signature

Station :
Drawing and Disbursing Officer /
Administrative Officer / Assistant
Director (Admn)
 NOMINATION FORM
TELANGANA STATE GOVERNMENT LIFE INSURANCE DEPARTMENT

To
The District Insurance Officer,
District Insurance Office (TSGLI),
_____________________.

In terms of Rule 31, Telangana State Government Life Insurance Department

Rules, I ______________________________ (Designation _____________________)
hereby nominate the persons specified in the schedule as beneficiaries to receive the
amounts stated against their / his / her names in case of my demise.

It is however, understood that this nomination will in no way affect my

right to surrendering Policy in case of my ceasing to be in service before the date of
maturity or to receiving amount myself on maturity of the Policy.

SCHEDULE NOMINEES
Sl. Name of the Nominees Age Relation to Policy No. Policies Share of
No. with Father's Name Policyholder (Suffixes) in Policy
which Amount to
Nomination each
(Change / New) nominee
is desired. i.e., (if any)
A, B, C, D, E etc.
01 02 03 04 05 06 07

Signature of the Policyholder with date

Certified that the above signature is of ___________________ son of ___________________

Signature of the Drawing & Disbursing Officer / AO with date and Stamp
 TSGLI MISSING CREDITS PROFORMA
NAME OF THE EMPLOYEE : …………………………………………………EMPLOYEE ID : ………………………………
DESIGNATION : …………………………………………………………. POLICY NUMBER : ……………………………………
PRESENT PLACE OF WORKING : …………………………………………………………………………………………………....

MONTHLY TOTAL
MONTH AND YEAR OF TOKEN
SUBSCRIPTION AMOUNT OF
S.NO POLICY AMOUNT NUMBER AND REMARKS
DEDUCTED IN THE
MISSING DATE
THE MONTH SCHEDULE

SIGNATURE OF THE DRAWING

AND DISBURSING OFFICER
GCP-J.No. 75-27-9-2022-50,000.

01/2014
LOAN FORM
s¡TD <Ûäs¡U≤düTÔ
Form No. 29
qeT÷Hê HÓ+. 29
Inward No.
n+‘·sêZ$T HÓ+.
TSGLI
DIRECTORATE OF INSURANCE
&Ó’¬sø£ºπs{Ÿ Ä|òt Çqü÷‡¬sHé‡ Office Use Only
ø±sê´\j·T|ü⁄ ñ|üj÷Ó >±s¡+ú
GOVERNMENT OF TELANGANA
‘Ó\>±D Á|üuTÑÛ ‘·«eTT
HYDERABAD
District Insurance Office : _______________
ôV≤’ <äsêu≤<é
õ˝≤¢ ;e÷ ø±sê´\j·T+ : _______________

APPLICATION FOR LOAN

s¡TDeTT ø=s¡≈î£ <äsU¡ ≤düTÔ

Policy No.
bÕ\d” HÓ+.
1. Name of the Subscriber #·+<ë<ës¡Tì ù|s¡T

2. Father’s Name ‘·+Á&ç ù|s¡T 3. Designation ¨<ë

D D MM Y Y Y Y
4. Date of Birth|ü⁄{Ϻq ‘˚~
(As per Service Register)
düØ«dt ]õwüºsY Á|üø±s¡+
5. Office where he is employed ñ<√´– |üì #˚j·TT#·Tqï ø±sê´\j·T+ ù|s¡T D.D.O. Code &ç.&ç.z. ø√&é

`
6. The Amount of Loan applied for <äsU
¡ ≤düTÔ #˚dTü ø=qï s¡TD yÓTT‘·+Ô
12 24 36 48
7. The Number of Instalments in which the Loan is proposed to be repaid ( )
(Not exceeding 48, according to Ruls 46)
s¡TD yÓTT‘·+Ô ‹]– #Ó*+¢ #·<\ä ∫q Á|ü‹bÕ~‘· yêsTT<ë\ dü+K´ (ìj·Te÷eä[ 46 Á|üø±s¡+ 48 yêsTT<ë\≈£î $T+#·sê<äT)
8. Basic Pay eT÷\ y˚‘·q+ ` Pay Scale J‘·|ü⁄ ùdÿ\T `

9. Gross Salary ` Total Deductions Net Salary

J‘·eTT yÓTT‘·Ô+ yÓTT‘·Ô+ ‘·–Z+|ü⁄\T ìø£s¡ J‘·+
10. Monthly Premium HÓ\dü] Á|”$Tj·TeTT yÓTT‘·+Ô `

11. Name of Bank where Payment of Loan is desired

s¡TD yÓTT‘·eÔ TT #Ó*+¢ |ü⁄ ø√s¡T#·Tqï u≤´+ø˘ ù|s¡T
Branch Name Áu≤+∫ ù|s¡T
IFSC CODE* ◊ m|òt j·Tdt dæ ø√&é
Bank Account No. * u≤´+≈£î U≤‘ê HÓ+ãs¡T
* Enclose First page of S.B. Account Pass Book (Xerox Copy)
Visit our website : www.tsgli.telangana.gov.in
 :: 2::

12. Employee I.D. No. ñ<√´– ◊&ç HÓ+ãs¡T

13. Aadhar Card No. Ä<ÛësY ø±sY¶ HÓ+ãs¡T

14. Mobile No. yÓTTu…’˝Ÿ HÓ+ãs¡T

15. E-Mail of policyholder bÕ\d”<ës¡Tì á`yÓTsTT˝Ÿ

16. Mobile No. of Drawing and ÄVü≤s¡D eT]j·TT ã{≤´&É

Disbursing Officer n~Ûø±] yÓTTu…’˝Ÿ HÓ+ãs¡T

17. E- Mail of Drawing and ÄVü≤s¡D eT]j·TT ã{≤´&É n~Ûø±] á`yÓTsTT˝Ÿ

Disbursing Officer

I hereby declare that the paticulars stated above are true and correct.
ô|’ ‘Ó*|æq $esê\T, dü¬s’qy˚qì Ç+<äTeT÷\eTT>± <ÛäèMø£]+#·T#·THêïqT.

I hereby authorise the Director of Insurance, Government of Telangana 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 Fund

J$‘· ;e÷ XÊK ìj·Te÷\ Á|üø±s¡+, ;e÷ XÊK &Ó’¬sø£ºs¡T ìπs› •+∫q Ø‹˝À e&û¶‘√ bÕ≥T s¡TD yÓTT‘êÔìï Hê J‘·+ qT+&ç ‹]– edü÷\T #˚ùd+<äT¬ø’ ‘·>∑T
ñ‘·Ôs¡T«\T C≤Ø #˚j·T&ÜìøÏ ‘Ó\+>±D Á|üuÛÑT‘·« ;e÷ XÊK &Ó’¬sø£ºs¡T≈£î n~Ûø±s¡$TdüTÔHêïqT.

Date : Signature of Applicant / Beneficiary

‘˚~ : <äs¡U≤düTÔ<ës¡Tì dü+‘·ø£eTT

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 made in my presence. He obtained a Loan of Rs.
____________________________ from TSGLI out of which Rs. ______________________is still outstanding

ô|’ <äs¡U≤düTÔ˝À ‘Ó*|æq $esê\T Hê≈£î ‘Ó*dæq+‘·es¡≈£î eT]j·TT $X¯«dæ+∫q y˚Ts¡≈£î dü¬s’qy˚qì Ç+<äTeT÷\eTT>± <ÛäèMø£¡]+#·T#·THêïqT. l```````----
```````````````--ô|’ <äsU¡ ≤düTÔ ô|’ dü+‘·øe£ TT Hê düeTø£eå TT˝À #˚XÊs¡T. áj·Tq ;e÷ XÊK qT+&ç >∑‘+· ˝À s¡÷ˆˆ ``````````````````````````s¡TDeTT
bı+~e⁄Hêïs¡T. áyÓTT‘·eÔ TT qT+&ç s¡÷ˆˆ ````````````````````````Ç+ø± #Ó*+¢ #·e\dæe⁄qï~.

Signature of Drawing and Disbursing

Officer with Seal And Date
ÄVü≤s¡D eT]j·TT ã{≤«&É n~Ûø±] dü+‘·ø£eTT
‘˚~ ø±sê´\j·T eTTÁ<ä‘√
Station :
dü\ú eTT :

Date :
‘˚~ : Name
(In Block Letters )
ù|s¡T:

Visit our website : www.tsgli.telangana.gov.in

 :: 3::

Revenue Stamp
¬syÓq÷´ kÕº+|t

STAMP RECEIPT
s¡o<äT
Note : If the Amount exceeds Rs. 5,000/-, Revenue Stamp Shall be affixed
>∑eTìø£ : ô|’ø£+ s¡÷ˆˆ 5,000/` \≈£î $T+∫q≥¢sTT‘˚ kÕº+|ü⁄ n‹øÏ+#ê*.

Policy No. __________________

bÕ\d” HÓ+ãs¡T : ``````````````````

I ________________________________ have Received a sum of Rs. _________________________________

(Rupees _______________________________________________________________Only) From Directorate of
Insurance, Telangana, Hyderabad Vide Cheque / Online Payment No. _________________ dated :_____________________
towards santion of Loan / Settlement of Claim against my policies

l / leT‹ ``````````````````````````````````````````````````` nqT H˚ qT J$‘· ;e÷ XÊK &Ós¬’ ø£sπº ≥T, ôV≤’ <äsêu≤<äT yê] qT+&ç
s¡÷ˆˆ ````````----------------````````` (s¡÷bÕj·T\T``````````````````````````````````````````````````````````````
e÷Á‘·yT˚ ) ‘˚~: ````---```````````````````----HÓ+ãs¡T``````````````````````````````>∑\ #Ó≈î£ ÿ / ÄHé ˝…H’ é ù|yÓT+{Ÿ <ë«sê n+<äTø=qï≥T¢
Ç+<äTeT÷\eTT>± s¡o<äT n+<ä#d˚ Tü HÔ êïqT.

Signature of Applicant / Beneficiary

<äs¡U≤düTÔ<ës¡Tì dü+‘·ø£eTT

I hereby certify that the above Signature of Sri / Smt________________________________________________

is made in my presence.

l / leT‹ ``````````````````````````````````````````````#˚dqæ ô| ’ dü+‘·øe£ TT Hê düeTø£eå TT˝À #˚XÊs¡ì <Ûèä Mø£]#·T#·THêïqT.

Signature of Drawing and Disbursing

Officer with Seal And Date
ÄVü≤s¡D eT]j·TT ã{≤«&É n~Ûø±] dü+‘·ø£eTT
‘˚~, ø±sê´\j·T eTTÁ<ä‘√
Station :
düú\eTT :
Date :
‘˚~ : Name
(In Block Letters )
ù|s¡T:

Designation :
¨<ë :
Visit our website : www.tsgli.telangana.gov.in
 Declaration regarding loss of policy

I ______________________________ S/o, D/o _________________________________hereby

declare that the policy/ies No. ______________________________ has/have been lost and not

mortgaged with any Bank, Firm, Third Party or any financial institution towards any loan.

Signature of subscriber

/Attested/

Signature of certifying Gazetted Officer

Name, Designation and Office seal
 GUARDIAN SHIP DECLARATION

I ___________________________ S/O / D/O / H/O / W/O ____________________

hereby declare that the following minor sons and daughters of Late Sri / Smt

______________________________________ are under my care and guardianship.

Sl. No. Name Age

The above minors are my real ______________________________________

Place :

Date :

SIGNATURE

“Attested”
Signature of the Drawing and Disbursing Officer
Name, Designation and Office Seal
CERTIFICATE OF SPECIMEN SIGNATURES

This is to certify that the signatures of Sri / Smt / Kum

____________________ , Designation ______________ ,

Policy No. ___________ of this Office are hereby attested

below.

Full Signatures Initials

1. 1.

2. 2.

3. 3.

“ATTESTED”

Dated Signature with Stamp

DDO / AO concerned
GCP-J.No. 76-27-9-2022-50,000.

01/2014
CLAIM FORM
¬ø¢sTTyéT <äs¡U≤düTÔ
Form No. 12
qeT÷Hê HÓ+. 12
Inward No.
n+‘·sêZ$T HÓ+.
TSGLI
DIRECTORATE OF INSURANCE Office Use Only
&Ó’¬sø£ºπs{Ÿ Ä|òt Çqü÷‡¬sHé‡ ø±sê´\j·T|ü⁄ ñ|üj÷Ó >±s¡+ú
GOVERNMENT OF TELANGANA
‘Ó\>±D Á|üuTÑÛ ‘·«eTT
HYDERABAD
Refund Form No. 1 ôV≤’ <äsêu≤<é District Insurance Office : _______________
]|òü+&é bòÕs¡+ HÓ+. 1
õ˝≤¢ ;e÷ ø±sê´\j·T+ : _______________
APPLICATION FOR REFUND AMOUNT FROM THE DIRECTORATE OF INSURANCE, HYDERABAD
(To be filled by the Subscriber)
;e÷ XÊK &Ós¬’ ø£sπº ≥T ø±sê´\j·T+, ôV≤’ Á<ëu≤<äT qT+&ç yÓTT‘·+Ô yê|üdTü ø√s¡T‘·Tqï{Ϻ <äsU¡ ≤düTÔ
(Bìì #·+<ë<ës¡T |üP]Ô #˚j÷· *)
Policy No.
bÕ\d” HÓ+.
1. Name of the Subscriber #·+<ë<ës¡Tì ù|s¡T

2. Father’s Name ‘·+Á&ç ù|s¡T 3. Designation ¨<ë

4. Name of the Office and the District where the Subscriber was last in Service
#·+<ë<ës¡T düØ«düT ∫e] s√E\˝À |üì#˚dqæ ø±sê´\j·TeTT ù|s¡T, õ˝≤¢ ù|s¡T.

5. Date of Maturity D D MM Y Y Y Y 6. Date of Birth D D MM Y Y Y Y

bÕ\d” |ü]D‹ ‘˚~ |ü⁄{Ϻq ‘˚~

D D MM Y Y Y Y
7. a) Date of Retirement
m) |ü<äM $s¡eTD ‘˚~

Nature of Retirment Superannuation Voluntary Compulsory

|ü<äM $s¡eTD dü«uÛ≤e+ dü÷|üsêqT´j˚TwüHé dü«#·Ã¤+<ä ìs¡“+<Ûä

b) Month and Rate of Last Deduction of Premium

_) Á|”$Tj·T+ yÓTT‘êÔÔìï edü÷\T #˚dæq ∫e] HÓ\

8. Name of Bank where Payment is desired

#Ó*¢+|ü⁄ ø√s¡T#·Tqï u≤´+ø˘ ù|s¡T
Branch Name Áu≤+∫ ù|s¡T
IFSC CODE* ◊ m|òt j·Tdt dæ ø√&é
Bank Account No. * u≤´+≈£î U≤‘ê HÓ+ãs¡T
(Note : The xerox copy of the Bank Pass Book first page should be attached)
Visit our website : www.tsgli.telangana.gov.in
 :: 2::

9. Employee I.D. No. ñ<√´– ◊&ç HÓ+ãs¡T

10. Mobile No. yÓTTu…’˝Ÿ HÓ+ãs¡T

11. Aadhar Card No. Ä<ÛësY ø±sY¶ HÓ+ãs¡T

12. Office in which the subscriber has worked during the last (5) Years
#·+<ë<ës¡T ∫e] (5) @fi¯ó¢ |üdæ #˚dæq ø±sê´\j·T+ ù|s¡T

13. Full Address of the Applicant with Pin code

<äs¡U≤düTÔ <ës¡T |üP]Ô ∫s¡THêe÷ |æHé ø√&é ‘√ düVü‰

14. A) I have Obtained Rs. ______________ towards T. S. G. L. I. Loan and there is a balance Rs.______________
to be paid which may be recoverd alongwith interest from my Policy amount.
m) s¡÷ˆˆ ``````````````````` {Ï.mdt.õ.m˝Ÿ. ◊. qT+&ç s¡TD+ bı+~e⁄HêïqT. á yÓTT‘êÔìøÏ >±qT, s¡÷ˆˆ ```````````-----````````````
#Ó*¢+#·e\dæ e⁄qï~. á yÓTT‘êÔìï e&û¶‘√ düVü‰ Hê bÕ\d” yÓTT‘·Ô+ qT+&ç edü÷\T #˚düTø√e#·TÃqT.

B) I do hereby declare that if in future it is found that any excess payment was made to me in advertently,
I shall be held responsible to repay such excess amount and give my consent for deduction of the same
from my Pension.
_) @<ÓH’ ê n~Ûø£ yÓTT‘·+Ô bıs¡bÕ≥Tq #Ó*+¢ |ü⁄ »]–+<äì eTTqTà+<äT ø£qT>=ìq |üø+å£ ˝À, n{Ϻ n~Ûø£ yÓTT‘êÔìï ‹]– #Ó*+¢ #˚+<äT≈£î u≤<ÛTä ´&ÉH’Ó e⁄Hêïqì, n{Ϻ
yÓTT‘êÔìï Hê |æ+#Ûq· T qT+&ç ‘·–+Z #·Tø=H˚+<äT≈£î Hê düeTà‹ì ‘Ó*j·TCÒd÷ü ,Ô Ç+<äTeT÷\+>± Á|üø{£ +Ï #·T#·THêïqT.

Date : Signature of Subscriber

‘˚~ :

Ceretified that the above Signature of Sri / Smt. __________________________________________________

S/O___________________________________________is made in my presence.

ô|q’ #˚dqæ dü+‘·ø+£ / y˚dqæ u§≥q Áy˚* eTTÁ<ä l / leT‹ ```````````````````````````````````````````-----------``````````

(‘·+Á&ç ù|s¡T) `````````````````````````````````````yê]<äì <Ûèä Mø£]+#·&eÉ TsTTq~.

Signature of the DDO/AO With Seal

Station : n~Ûø±] dü+‘·ø£eTT   eTTÁ<ä :
düú\eTT :

Name of the Officer

Date : n~Ûø±] ù|s¡T
‘˚~ :

Office Seal Designation

ø±sê´\j·T+ eTTÁ<ä ¨<ë

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 :: 3::

Revenue Stamp
¬syÓq÷´ kÕº+|t

STAMP RECEIPT
s¡o<äT

Note : If the Amount exceeds Rs. 5,000/-, Revenue Stamp Shall be affixed
>∑eTìø£ : ô|’ø£+ s¡÷ˆˆ 5,000/` \≈£î $T+∫q≥¢sTT‘˚ kÕº+|ü⁄ n‹øÏ+#ê*.

Policy No. __________________

bÕ\d” HÓ+ãs¡T : ``````````````````

I __________________________________ have Received a sum of Rs. _____________________________

(Rupees__________________________________________________________________Only) From Directorate of
Insurance, Telangana, Hyderabad Vide Cheque / Online Payment No. _________________ dated :__________________
towards santion of Loan / Settlement of Claim against my policies

l / leT‹. ````````````````````````nqT H˚qT J$‘· ;e÷ XÊK &Ó’¬sø£ºπs≥T, ôV’≤<äsêu≤<äT yê] qT+&ç s¡÷ˆˆ ```````````````````````
(s¡÷bÕj·T\T`````````````````````````````````````````````````````````````` e÷Á‘·yT˚ ) ‘˚~: `````````````````---````````
HÓ+ãs¡T``````````````````````````````>∑\ #Ó≈î£ ÿ / ÄHé ˝…H’ é ù|yÓT+{Ÿ <ë«sê n+<äTø=qï≥T¢ Ç+<äTeT÷\eTT>± s¡o<äT n+<ä#d˚ Tü HÔ êïqT.

Signature of Applicant / Beneficiary

<äs¡U≤düTÔ<ës¡Tì dü+‘·ø£eTT

I hereby certifiey that the above Signature of Sri / Smt. ___________________________________________

is made in my presence.

l / leT‹ ```````````````````````````````````````````````````#˚d qæ ô|’ dü+‘·øe£ TT Hê düeTø£eå TT˝À #˚XÊs¡ì <Ûèä Mø£]+#·T#·THêïqT.

Signature of Drawing and Disbursing

Officer/A.O. with Seal and Date
ÄVü≤s¡D eT]j·TT ã{≤«&É n~Ûø±] dü+‘·øe£ TT
‘˚~ ø±sê´\j·T eTTÁ<ä‘√
Station :
düú\eTT :
Date :
‘˚~ : Name of Drawing and
Disbursing Officer / AO
ÄVü≤s¡D eT]j·TT ã{≤«&É
n~Ûø±] ù|s¡T:
Designation :
¨<ë :
Visit our website : www.tsgli.telangana.gov.in
GCP-J.No. 77-27-9-2022-50,000.

01/2014
DEATH CLAIM FORM
eTs¡D ¬ø¢sTTyéT bòÕs¡+
Please affix claimant’s
Photo, duly attested by
the DDO Inward No.
(If the DDO is not in n+‘·sêZ$T HÓ+.
Gazetted Rank, it
should be attested by
the Departmental G. O. TSGLI
only)
Office Use Only
ø±sê´\j·T|ü⁄ ñ|üj÷Ó >±s¡+ú
DIRECTORATE OF INSURANCE
&Ó’¬sø£ºπs{Ÿ Ä|òt Çqü÷‡¬sHé‡
GOVERNMENT OF TELANGANA
‘Ó\>±D Á|üuTÑÛ ‘·«eTT
HYDERABAD
ôV≤’ <äsêu≤<é
Refund Form-2
]|òü+&é bòÕs¡+ `2 District Insurance Office : _______________

õ˝≤¢ ;e÷ ø±sê´\j·T+ : _______________

(To be filled by the Heir of the Subscriber)

(#·+<ë<ës¡T yês¡dTü \T uÛØÑ Ô #˚jT· e˝…qT)
All Columns Shall be filled in capitals only
nìï ø±\eTT\T ô|<ä› nø£ås¡eTT\‘√ |üP]Ô>± ì+|üe˝…qT

Policy No. Employee ID No. Claimant’s Mobile No.

bÕ\d” HÓ+. ñ<√´– ◊&ç HÓ+ãs¡T. \_∆<ës¡Tì yÓTTu…˝’ Ÿ HÓ+ãsY

1. Name of the Subscriber #·+<ë<ës¡Tì ù|s¡T

2. Father’s Name ‘·+Á&ç ù|s¡T 3. Designation ¨<ë

4. Name of the Office and the District where the Subscriber was working at the
time of Death
#·+<ë<ës¡T #·ìb˛j˚THê{ÏøÏ |üì#˚dqæ ø±sê´\j·TeTT ù|s¡T, õ˝≤¢ ù|s¡T.

5. Date of death of the subscriber specifying the D D M M Y Y Y Y

disease / cause of death
#·+<ë<ës¡T #·ìb˛sTTq ‘˚~, yê´~Û $es¡eTT\T

6. Name of the Claimant and his / her Father’s Name Relationship with deceased Policy holder
¬ø¢sTTeTT #˚j·TT#·Tqï yê] ù|s¡T eT]j·TT yê] ‘·+Á&ç ù|s¡T #·ìb˛sTTq #·+<ë<ës¡Tì‘√ >∑\ ã+<ÛäT‘·«+

7. Date and reason of retirment D D MM Y Y Y Y

|ü<äM $s¡eTD ‘˚~, ø±s¡DeTT\T.

Visit our website : www.tsgli.telangana.gov.in (Contd -2

8. Name of the Wife or Husband of the deceased with their
children and age
#·ìb˛sTTq e´øÏÔ jÓTø£ÿ uÛ≤s¡´ ˝Ò<ë uÛÑs¡Ô ù|s¡T¢, |æ\¢\ ù|s¡T¢ eT]j·TT ej·TdüT‡

9. Name of the Bank where payment is desired

#Ó*¢+|ü⁄ ø√s¡T#·Tqï u≤´+ø˘ ù|s¡T

Branch Name Áu≤+∫ ù|s¡T

IFSC CODE* ◊ m|òt j·Tdt dæ ø√&é
Bank Account No. * u≤´+≈£î U≤‘ê HÓ+ãs¡T
Mobile No. of Claimant \_ú<ës¡Tì yÓTTu…’˝Ÿ HÓ+ãs¡T

Aadhar Card No. Ä<ÛësY ø±sY¶ HÓ+ãs¡T

(Note : The Bank Pass Book first page Xerox Copy of the claimant Should be attached)

10. Full Address of claimant with Pin Code.

\_›<ës¡Tì |üP]Ô ∫s¡THêe÷ |æHé ø√&é ‘√ düVü‰

Important Note : In case of dispute the claim will be settled in terms of Rule 32 (d) (3) of Telangana State
Government Life Insurance Fund Rule

eTTK´>∑eTìø£ : @<˚$ $yê<äeTT ñqïjÓT&É\ á XÊK jÓTTø£ÿ ìã+<Ûäq 32 (&ç) (3) Á|üø±s¡+ #Ó*¢+|ü⁄ |ü]wüÿ]+#·ã&ÉTqT.
DECLARATION
Á|üø≥∑£ q
I do hereby declare that there are no other widow or widows of the deceased or minor sons and unmarried daughters born of
them except those mentioned in this Application. If in furture any other Claimants or minor heirs mentioned in the
Application Claim payment of their share in the amount on attaining majority, I shall be held responsible to repay the amount.
I also declare that if in future it is found that any excess payment was made to me inadvertently, I agree to repay such execss
amount.

á <äs¡U≤düTÔ˝À ‘Ó\T|üã&çq yês¡T ˝Òø£ #·ìb˛sTTq e´øÏÔøÏ $‘·+‘·Te⁄ ˝Ò<ë $‘·+‘·Te⁄\T ˝Ò<ë yê]øÏ ø£*–q yÓTÆqs¡T ø=&ÉT≈£î\T ô|+&ç¢ ø±ì ≈£îe÷¬sÔ\T mes¡÷ ˝Òs¡ì
Ç+<äTeT÷\eTT>± Á|üø{£ +Ï #·&yÉ TÓ qÆ ~. Ç‘·s¡ Vü≤≈£îÿ<ës¡T¢ ˝Ò<ë á <äsU¡ ≤düT˝Ô À ‘Ó\T|üã&çq yÓTqÆ s¡T yês¡dTü \T y˚T»s¡T¢ nsTTq MT<ä≥ áô|ø’ e£ TT˝À ‘·eT yê{≤qT uÛ$Ñ wü´‘·T˝Ô À
ø√s¡T |üø£åeTT˝À Ä yÓTT‘·ÔeTTqT ‹]– #Ó*¢+#·T≥≈£î H˚qT u≤<ÛäT´&ÉHÓ’ ñ+&É>∑\qT. ˇø£y˚fi¯ bıs¡bÕ≥Tq @yÓTÆHê m≈£îÿe yÓTT‘·ÔeTT bı+~j·TTqï jÓT&É\ n{Ϻ yÓTT‘·ÔeTTqT ‹]–
#Ó*+¢ #·T≥≈£î u≤<Û´ä ‘· eVæ≤+‘·Tqì Ç+<äTeT÷\eTT>± Á|üø{£ +Ï #·T#·THêïqT.

Signature / Left Hand Thumb Impression of the Applicant/ Claimant

<äs¡U≤düTÔ<ës¡T dü+‘·ø£eTT / y˚*eTTÁ<ä
CERTIFICATE
dü]º|òæ¬ø{Ÿ
Certified that the entries made in the Application are correct, the details of which are known to me. There is no other
legal heir of deceased except those mentioned in the Application and the Signature or Thumb - Impression is of
Sri / Smt_______________________________________________________________________ widow of / guardian
of _________________________________________________________________regarding which I am fully satis-
fied.
It is also certified that the last working days Salary was paid to the Claimant only and the deceased Subscriber was in
Service till Death

The Subscriber obtained a Loan of Rs. _________________against his TSGLI Policy and if any outstanding Loan or
Interest is payable, the same can be recovered from the Policy amount.

Visit our website : www.tsgli.telangana.gov.in (Contd -3)

 :: 3::

<äsU¡ ≤düT˝Ô À #˚dqæ qyÓ÷<äT\T düÁø£eTyÓTqÆ eìj·TT, Ä $es¡eTT\T H˚qT m]–q y˚qqìj·TT <Ûèä e|üs#¡ &· yÉ TÓ qÆ ~. á <äsU¡ ≤düT˝Ô À ‘Ó\T|üã&çq yês¡T Hê´j·Tã<Ûy∆ä TÓ qÆ
Ç‘·s¡ yês¡dTü \T me«s¡÷ ˝Òsì¡ j·T÷ dü+‘·øe£ TT ˝Ò<ë y˚* eTTÁ<äl / leT‹````````````````````````````````````````````````````` $‘·+‘·Te⁄ /
dü+s¡ø≈å£ î£ &ÉT #·+<ë<ës¡Tì ∫e] s√E\ J‘· uÛ‘Ñ ´· eTT\T Á|üdTü ‘Ô · \_∆<ës¡TìøÏ #Ó*+¢ #·&eÉ TsTTq<äì eT]j·TT #·ìb˛sTTq ‘˚~ es¡≈î£ düØ«düT˝ÀH˚ ñHêï&Éì <Ûèä Mø£]+#·T#·THêïqT.

Signature of the Drawing and Disbursing Officer /A.O

Office Seal (If D.D.O is not in Gazzetted rank, the Next Gazetted Officer’s
ø±s¡´\j·T+ eTÁ<ä Counter Signature Should be Obtained)
ÄVü≤s¡D eT]j·TT ã{≤«&Ü n~Ûø±] dü+‘·ø£+

Name of the Officer :

In Block Letters:

$&ç nø£ås¡eTT˝À n~Ûø±] ù|s¡T :

Designation :
¨<ë :
Name of the Office :
ø±sê´\j·T+ ù|s¡T :
Note :- 1. The Application should be certified by the conerned Drawing and Disbursing Officer / A.O. only
>∑ e Tìø£ : 1. á <äsU¡ ≤düTqÔ T dü+ã+~Û‘· ÄVü≤s¡D eT]j·TT ã{≤«&Ü n~Ûø±] e÷Á‘·yT˚ <Ûèä Mø£]+#·e˝…qT
2. If the Subcriber dies within (3) Years of issue of Policy / Policies, the Drawing and Disbusing Officer shall
furnish the detials of Leave on Medical Grounds availed for the period (3) Years (along with attested Xerox
Copies of Medical Certificate) Preceeding the date of commencement of Policy /Policies.

2.: #·+<ë<ës¡T&ÉT bÕ\d” ÁbÕs¡+uÛ|Ñ ⁄ü ‘˚~ qT+&ç (3) dü+e‘·‡s¡eTT˝À|ü⁄ eTs¡D+Ï ∫qjÓT&É\, nVü≤s¡D eT]j·TT ã{≤«&Ü n~Ûø±] dü<sä T¡ #·+<ë<ës¡T&ÉT bÕ\d”
ÁbÕs¡+uÛÑ|ü⁄ ‘˚~øÏ eT÷&ÉT dü+e‘·‡s¡eTT\ ø±\eTTqT≈£î yÓ’<ä´ ø±s¡DeTT\ ô|’ yê&ÉTø=ìq ôd\e⁄ $es¡eTT\qT (<ÛäèMø£]+∫q õsêø˘‡ yÓ’<ä´ dü]º|òæ¬ø{Ÿ \‘√)
‘·|üŒì dü]>±, á <äs¡U≤düTÔ‘√ |ü+|üe˝…qT.
3. The Following Douments also shall be compulsorily enclosed.
~>∑Te ‘Ó*|æq |üÁ‘·eTT\T ≈£L&Ü ‘·|üŒø£ »‘· #˚j·T<ä˝…qT.
Enclosures :
»‘· #˚j·Te\dæq$ :
a). Original Policy Bonds
m). bÕ\d” |üÁ‘·eTT\T
b). Legal Heirs Certificate / Family Members Certificate Copy duly attested
_). yês¡d‘ü «· |ü⁄ |üÁ‘·eTT <Ûèä Mø£sD¡ ‘√
c). Death Certificate Copy duly attested
dæ). eTs¡D <ÛäèMø£s¡D |üÁ‘·eTT <ÛäèMø£s¡D‘√
d) First Page of S.B. Account Pass Book (Xerox Copy)
&ç). u≤´+≈£î bÕdt ãTø˘ yÓTT<ä{Ï ù|õ õsêø˘‡ ø±|ò”
e) .Departmental Information form (9 Columms)
Ç). XÊFj·T düe÷#ês¡ |üÁ‘·eTT.

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 :: 4::

Revenue Stamp
¬syÓq÷´ kÕº+|t

STAMP RECEIPT
s¡o<äT
Note : If the Amount exceeds Rs. 5,000/-, Revenue Stamp Shall be affixed
>∑eTìø£ : ô|’ø£+ s¡÷ˆˆ 5,000/` \≈£î $T+∫q≥¢sTT‘˚ kÕº+|ü⁄ n‹øÏ+#ê*.

Policy No. __________________

bÕ\d” HÓ+ãs¡T : ``````````````````

I ________________________________ have Received a sum of Rs. ___________________________
(Rupees _____________________________________________________Only) From Directorate of
Insurance, Telangana, Hyderabad Vide Cheque / Online Payment No. _______________________________
dated :_____________________ towards sanction of Loan / Settlement of Claim against my policies

l / leT‹ ```````````````````````````nqT H˚qT J$‘· ;e÷ XÊK &Ós¬’ ø£sπº ≥T, ôV≤’ <äsêu≤<äT yê] qT+&ç s¡÷ˆˆ `````````````
(s¡÷bÕj·T\T``````````````````````````````````````````````````````````````````````````````````e÷Á‘·yT˚ )
‘˚~: ``````````````````````````HÓ+ãs¡T``````````````````````````````>∑\ #Ó≈£îÿ / ÄHé ˝…’Hé ù|yÓT+{Ÿ <ë«sê n+<äTø=qï≥T¢
Ç+<äTeT÷\y˚T>± s¡o<äT n+<ä#d˚ Tü HÔ êïqT.

Signature of Applicant / Beneficiary

<äs¡U≤düTÔ<ës¡Tì dü+‘·ø£eTT

I hereby certify that the above Signature of Sri / Smt.___________________________________________

is made in my presence.

l / leT‹. ``````````````````````````````````````````````#˚dqæ ô|’ dü+‘·øe£ TT Hê düeTø£eå TT˝À #˚XÊs¡ì <Ûèä Mø£]#·T#·THêïqT.

Signature of Drawing and Disbursing

Officer/A.O. with Seal And Date
ÄVü≤s¡D eT]j·TT ã{≤«&É n~Ûø±] dü+‘·ø£eTT
‘˚~, ø±sê´\j·T eTTÁ<ä‘√
Station :
düú\eTT :
Date :
‘˚~ : Name
(In Block Letters )
ù|s¡T:

Designation :
¨<ë :

Visit our website : www.tsgli.telangana.gov.in

GCP-J.No.79-27-09-2022-50,000

T.S.G.L.I.D.No. 19

DEATH CERTIFICATE

It is hereby certified that Sri / Smt. _____________________________________

S/o / D/o ____________________________________________ Ex - employee (Department

___________________________________________________________________________

who has undergone my treatment / Whom I know died of (Disease / Cause )___________

________________________________ on (Date) __________________________________

at (Place) ___________________________________

Signature of the Certifying Officer.

Name, Designation and Office Seal

Note :- This Certificate should normally be issued by the Medical officer concerned. It may also
be issued by a Private Practitioner or a non-Gazetted Officer, in this case, it should
invariably be countersigned by a Gazetted Officer in service. As an alternative it may also
be issued by any Gazetted Officer in service who knew the deceased.
 INDEMNITY BOND

THIS INDEMNITY BOND made and executed in exercise of the executive power of
the date this _________________ day of ___________________.

BETWEEN THE GOVERNOR OF TELANGANA hereinafter called the

(“Government” which term shall include his successors in Office) of the one part;
AND (1) __________________________ S/O / D/O __________________________
aged _____ years, occupation ____________________________________________
residing at ___________________________________________________________
AND (2) _________________________ S/O / D/O ___________________________
aged _____ years, occupation __________________________________ residing at
____________________________________ Hereinafter called the “Sureties” (which
term shall include their heirs, successors and legal representatives) of the other part;

WHEREAS Sri ________________________ S/O / D/O _________________

Employee of the ______________________ Department, Government of Telangana
who was a subscriber to the Telangana State Govt. Life Insurance Fund (hereinafter
referred to as the “Fund”) died on ____________ leaving behind him surviving heirs
(sons, daughters etc.,) (1) ____________________________________ (2)
______________________________ (3) _______________________________ etc.,

AND WHEREAS a sum of I. G. Rs. __________________________________

(in words) was payable to the said subscriber at the date of his death by the fund.

AND WHEREAS the said heirs have applied to the Government to pay to him /
her / them the said sum of Rs. __________________________________________
(in words) and the Government have agreed to pay the said sum on his / her / their
producing an Indemnity Bond with two sureties.

AND WHEREAS we, the above named, have agreed to stand sureties for the
said heir or heirs.

NOW THEREFORE this deed witnessed as follows :-

1. That we, the above named sureties shall indemnify and keep indemnified
the Government against all claim, suits, proceedings, actions, costs, charges and
expenses which shall or may be referred, instituted or arise in consequence of the
Government paying the said sum of Rs. ____________________________________
_____________________________ (in words) to the said heir or heirs.

2. That we, the above named, sureties further declare that if the Government
suffers any loss, we shall make up such loss. In the event of default on our part,
the Government shall be at liberty to recover the amount of loss from our person
and property under the provisions of the Hyderabad Government Demands Act (IV
of 1308 Fasli) or under any other law for the time being in force in that behalf.

(Contd – 2)
 :: 2 ::

IN WITNESS WHEREOF we, the above, sureties have affixed our signatures
on the date and year herein above written in the presence of the following two
witnesses :-

WITNESSES :

(1) Name, Address & Signature (1) Signature of the first surety

Name :

TSGLI Policy No.

(2) Name, Address & Signature (2) Signature of the second surety

Name :

TSGLI Policy No.

Attestation of the
Departmental Gazetted Officer
(with Name, Designation & Office Stamp)