Annexure (C)
JAMMU AND KASHMIR STATE INSURANCE
APPLICATION FOR ASSURANCE
(Referred to in Rule 12)
Statement to be made by a person applying for Insurance under the Government Employee's
Compulsory Insurance Scheme.
1. (a) Full Name and Surname (Block letters) (a). _____________________________________
(b) Father's Name (Block letters) (b). ______________________________________
2. (a) Date of birth (attested copy of 1st page
of Service Book attached in support) (a). ______________________________________
(b) Age to be on next birthday (b). _______________________________________
3. (a) Permanent address (a). _______________________________________
(b) Present address (b). _______________________________________
4. (a) Full particulars of appointment held under(a). ______________________________________
the Government/Designation and the
Department/Office in which employed)
(b) Date of joining Government service (b). _______________________________________
5. Married/ Unmarried
6. (a) Scale of pay of the post held ( a). _______________________________________
(b) Monthly Band Pay excluding Grade Pay (b). _______________________________________
7. Amount of policy applied for (in accordance
with the Schedule given below) . __________________________________________
(Note:-Not exceeding Rs, 2,00,000)
8. Description of nominees to whom the benefit is to be paid in the event of the death of the
Insurant before the policy matures/death before the receipt of policy proceeds by the insurant.
S. No Name of the Nominee Age Relation with Present address (of the
the Insurant Nominee)
(b)
Details of Date of taking of Amount of policy taken Amount of premiumn
policy/policies already Insurance Policy
drawn under the State
Insurance Fund
SCHEDULE
MINIMUM SUM TO BE ASSCRED EMPLOYEES MONTHLY BAND PAY EXCLUDING GRADE PAY FALLS
(a) Up to Rs. 5200/- PM
(b) From Rs. 5201/-PM to 9300/- PM
(c) From Rs. 9301/- to Rs. 15600/- PM
(d) From Rs. 15601/- PM to above Rs. 25,000/- Rs.50,000/ Rs.1,00,000/-
Rs.1,50,000/-
(e) Maximum limit of sum assured Rs.2,00,000/
Note: - An employee may. however, insure for an amount of Rs2,00,000/ higher than that which he
has to take compulsory but such amount shall not exceed Rs. 2.00,000/ and it should either be one
or the stipulated amount indicated in the above schedule or Rs. 2,00,000/-
Place _______________
Date________________ Signature/Designation of applicant
Certificate by applicant's immediate superior.
It is certified that the particulars given above by the proposer are correct and nothing has been
deliberately concealed.
Dated______________ Signature
Designation with Stamp of
D.D. O
FIRST PAGE OF THE SERVICE BOOK
Name. ________________________________________________ Race. ____________________
Address.__________________________________________________________________________
Date of birth by Christian era as
nearly as can be ascertained (with source). ______________________________________________
Exact height by measurement. _______________________________________________________
Personal marks of ldentification. ______________________________________________________
Signature and Designation of the Head of
The Office or other Attesting Officer
Seal and Signature of the Drawing Officer
Attested true copy:
Note: -
Necessary requisite documents required for entry in the State Insurance Fund
1. Filing of application form by applicant and countersigned by D. D. O.
2. Photostat copy of first page of service book duly attested by D. D. O.
3. Photostat copy of permanent appointment order copy duly attested by D. D. O.
4. Covering letter
