VELLORE DIVISION
ANNEXURE - I
M.R. No.Date :
BRANCH OFFICE :
Amount :
Registration No.
ANNEXURE TO APPLICATION FOR APPOINTMENT TO ACT AS AN INSURANCE AGENT
(Grant of Agency will be subject to the provisions of Insurance Regulatory and Development Authority of India Guidelines for Appointment of Insurance Agents, 2015)
1)
(a) Name : Mr. / Mrs./ Miss.
(In Block letters, Surname First)
(b) Nationality :
(c) Sex :M/F
(d) Category :Gen/SC/ST/OBC
(e) Marital Status : Married/Unmarried/Widow/Widower/Divorcee
(f) What has been your usual state of health :
(g) Do you have any bodily defect or deformity, if so give details
(2)
Bank Account Details : (a) Nature of account
(b) Name of Bank
(c) Account No.
(d) IFS Code
(Enclose cancelled cheque leaf / first page of Bank Pass Book)
3)
Phone No. Land Line with STD Code
Mobile No.
Do you wish to receive communications through SMS on the above mobile number? Y/N
4)
E-mail ID :
Do you wish to receive communications through email on the above e-mail ID? Y/N
5)
Whether sponsored by a Development Officer/CLIA : Yes/No.
6)
If sponsored by a Development Officer/CLIA then following details to be furnished :
(a) Name of the Development Officer / CLIA
(b) His / her code Number
(c) His / her Branch Office
(d) His / her Divisional Office
7)
Are you related to any of the Corporation's :
(a) Existing Employees (Development Officers, Officers on Administrative or Development side, Staff Members)
(b) Ex-employees
(c) Existing Agents
(d) Ex-agents
(e) Medical ExaminerOR
(f) Are you an employee of a Medical Examiner?
If your answer is 'YES' to any off the above please give the following particulars about his / her applicable:
NameDesignation
Relationship with youAgency Code No.
Officer under which he / she worksDate of cessation of Agency
Name of the Development OfficerCode No.
8)
Is your spouse in the service of State / Central Government / Public sector undertaking, including Town Municipality, Municipal Corporation, Zilla Parishad, Gram Panchayat etc? : YES/NO
If yes, No objection certificate from employer's required
What is your Guardian's / Husband's / Wife's Occupation :
State his / her office Address :
9)
(a) What is your present occupation?
(b) If in employment, state full name and address of employer and nature of employment
(c) Whether permission to take agency is required. Yes/No.
If Yes, Whether same has been taken.
(d) Have you ever been adjudicated insolvent, applied for insolvency or compounded with your creditors?
10)
Are you having or had at any time an agency doing General Insurance business / Unit Trust of India / Public Provident Fund or in any other Investment / Chit Company? If so,
(a) Name of the Organisation
(b) Address
(c) Your code number if any
11)
Have you ever held a licence, State Number and Date of Expiryotherwise say "NIL".
12)
If the applicant holds a certificate to act as a Principal Agent and / or a Chief Agent and or a Special Agent, State No. and Date of expiry of the certificate or certificates held; if no certificate is held, say "NIL", if any such certificates has been applied has been applied for, state the date of the application.
13)
(a) Give details of your past business experience
(b) State your personal environments, special facilities or business or personal connections you have or on which you depend or count upon for influencing business.
14)
Nominee :
Relationship :
Age :
In the event of cessation of my agency due to any reason what so ever, I shall return my Appointment letter and ID card to the Branch to which I am attached.
I agree to abide by the terms and conditions as laid down in various Regulations and Acts governing Life Insurance agency.
I do hereby declare that the foregoing statements and answers are to the best of my knowledge and belief, true and complete and they shall be the basis of contact of the agency between me and the Life Insurance Corporation of India and that if the foregoing statements or answers are untrue or incomplete the said contract shall stand automatically terminated from the date on which such knowledge comes to the Corporation. I hereby confirm that this Agency Application has been completed by me in my own handwriting.
Date
Place
Signed in my presence
_________________________
Signature of the Applicant
Signature of the Applicant
(Signatue of Witness)
Name, Designation and Address