You are on page 1of 1
cu JRITY VALUE OF POSTAL/ RURAL POSTAL LIFE IN! Y {Please fil in the columns in CAPITAL letters) 41, Name of Insurant (Mr. Mrs. Ms.) estore se nae Lat ene 1 TTTTTITrTrTryrrTrittrtrrrrTrTrritrititrrrir) 2. Occupation CEETTTTrrrrererrrrrrrrrr rrr rrr tir ittr) 3. Communication Addross Vilage Gi Slate 4, Patieulars of Policy | Pole No (SF NO 1 Sum Assured li. Date of Acceptance Iv. ba ot sua Bots EA Pte) ELIITTTTTTA-) = CLT Titty) Litt tt ttt) Date of Metury 171 1 TT 5.) Designation and Address of Drawing and Disbursing Officer during test six months, Vil Taluka ily Distt State ‘Count ii Name ofthe Post Office where premia were paid during last six months a) > ° * 8 i 6. Name ofthe Post Office (it's Sub Office, write the name of Head Oifice as well) at which the payment is desired |. Name of Sub Post Office a ¥ Mee tte Poa nen TT TTTTTTTTrrrrrrr rrr rr rrrrrt tri LaccoutNo. §[TTTTTTTTTrrrTrrrrrtrrtrri rrr W Name of Post orfesi Bank [TT TT TTTTTTTTTTTrTTrrTrtrrtrrirritr) Wi, Branch Name: (TT TTT TTTTTITTTT Tt tT trtt tt ttt ocuments attaches (a) Policy document. (©) Loan Repayment Receipt Book if oan was taken. (6) Premium Receipt Book (@) Certificate of Pay Disbursing Officer regarding recovery of premia from pay forthe last six months. (@) Any other document Dat: ‘Signature of insurant Name: Phone no, Office: Residence: Mobile no. : PSEVAML-PTEINS-09/6-17 JAY PRINTCARE 20000 FORM

You might also like