JAMMU AND KASHMIR STATE INSURANCE
APPLICATION FOR ASSURANCE
(REFERRED TO IN RULE 12)
Statement be made by a person applying for insurance under the
Government Employee's Compulsory Insurance Scheme
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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 a)
of service book attached in Support)
b) Age to be on next birthday b)
3. a) Permanent address a)
b) Present address b)
4. a) Full. particulars of appointment held a)
Under the Govt. /Designation ft the
Department/Office in which employed
b) Date of joining Govt. Service b)
5. a) Married/Un-married
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) ______________
> Mobile No/ e-Mail ID
8. Description of nominees to whom the benefits is to be paid in the event of the death of
the lnsurant before the policy matures/death before the receipt of policy proceeds by
the lnsurant
S. No. Name of the Nominee Age Relation with the Present address (of Nominee)
lnsurant
b)
Details of policy/policies already Date of taking of Amount of Policy Amount of premium
drawn under the state insurance Insurance Policy taken
Fund
Signature of Applicant
[2]
SCHEDULE MINIMUM SUM TO BE ASSURED
EMPLO YEES MONTHLY BAND PAY EXCLUDING GRADE PAY FALLS
a)
Rs. 25,000/
Upto Rs. 5200/-PM (Level SL1 to Level 1)
b)
Rs. 50,000/
From 5201/-PM to 9300/-PM (Level 2 to Level 6)
c) Rs. 1,00,000/
From 9301/-PM to I 5600/-PM (Level 7 to Level 10)
d) From 15601/-PM to above (Level 11 and above) Rs. 1,50,000/
e) Maximum limit of sum Assured Rs. 2,00,000/-
Note:-
An employee may, however,lnsure for an amount of Rs.2, 00, 000 /-higher than that which
he has to take compulsorily but such amount shall not exceed Rs.2,0 0,000 /-and it should
either be one or the stipulated amount indicated in the above schedule or Rs. 2, 00 , 000 /-
Place
Date : ___________ Sig11ature/Desig11ation 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.
Signature
Date:- ___________ Designation with Stamp of D. D. 0.
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 identification
Signature and designation of the Head
of the Office or other Attesting_ Officer
Attested True Copy
Note :-
Necessary Requisite documents required for entry in the State Insurance
Fund
1. Filling 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. 0.
4. Covering letter.
