VELLORE DIVISION
FORM I - A
Paste Self
attested
Passport
size
Photograph
attested
Passport
size
Photograph
APPLICATION FOR APPOINTMENT TO ACT AS AN INSURANCE AGENT
(With a Life Insurer OR General Insurer OR Health Insurer)
To,
(Name of the Insurer)
DEAR SIRS,
I request that Appointment to act as an insurance agent of your organisation may be granted to me.
I hereby declare that particulars given below are true and that the APPOINTMENT for which I apply will be used only by myself for soliciting or procuring insurance business for your insurance Organisation.
(1) Name :
(2) Title: State 1. if Mr. :
2. Mrs. :
3. Miss. :
(3) Father's / Husband Name :
(4) Full Address :
| House No. | |||
| Street | |||
| Town | |||
| District | |||
| State | |||
| Pin code | |||
| Mobile No. | E-mail : id | ||
(5) Date of Birth : Day - Month - Year
Attach Age Proof
(6) Educational Qualifications (Tick the right Box) (Attach self-attested certificate)
| Class X | Class XII | Graduate | Post Graduate | Others |
|---|---|---|---|---|
(7) PAN CARD Number
attach self-attested copy of the PAN CARD
(7A) Licence Number
(8) Particulars of pass in pre-recruitment test conducted by the Insurance Institute of India or any Examination Body :
| Name of Examination Body : | ||
| Candidate's Name : | ||
| Candidate's Number : | ||
| Centre of Examination : | ||
| Name of the Exam Passed | ||
| Date of Passing | (Day - Month - Year) | |
(9) Furnish the details of any Insurance agency in force or ever hold by the applicant :
| Name of the Insurer | Agency Code Number | Date of Appointment as agent | Date of cessation of Agency | Reason for cessation of Agency |
|---|---|---|---|---|
* Please attach Agency cessation letter issued by the Insurer
(10) Details of other insurance related activities undertaken, if any :
11. I declare that ....
(a) I have not been found to be of unsound mind by a court of competent Jurisdiction;
(b) I have not been found guilty of criminal misappropriation of criminal breach of trust or cheating or forgery or an abatement of or attempt to commit any such offence by a court of competent jurisdiction;
(c) I have not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or mis- representation against an insurer or an insured.
Yours faithfully,
Place :
Date :
Signature of applicant
NOTES AND INSTRUCTIONS :
- The application should be filled in Hindi or English language.
- Any correction or alteration made in any answer to the questions in the application should be initialled by the applicant.
- An applicant must be at least 18 years and above of age on the date of the application. The applicant shall furnish proof of age.
- An applicant shall furnish the proof of pass in the pre-recruitment exam conducted by an examination body duly recognized by the Insurance Regulatory and Development Authority of India.
- The following documents should be attached with the application :
(a) Age Proof
(b) Educational Qualifications
(c) Proof of pass in the agency examination as mentioned above
(d) Copy of PAN card
(e) Address proof to the satisfaction of the insurer.