FORMI-B
APPLICATION OF AN EXISTING INSURANCE AGENT FOR APPOINTMENT
TO ACT AS COMPOSITE INSURANCE AGENT WITH ANOTHER INSURER
(LIFE ORGENREAL OR HEALTH INSURANCE or MONO-LINE INSURANCE)
NAME OF INSURANCE AGENT SATYENDRA KVMAR
DETAILS OF THE INSURANCE AGENCY HELD (Past &s Present)
Name of the Agency code Date of Date of Reason for
Insurer Number Appointment cessation of cessation of
as agent Agency agency
LLULAR090 -10-202
Note If Agency is currently in-force with an insurer mention
"INFORCE" in the column Date of cessation of Agency
cOMPOsITE INSURANCE AGENCY APPOINTMENT now being sought with
Life Insurer rCerPRUDNNTIALLCFR
General Insurer
Health Insurer
Other Mono-Line Insurer
** Mention name of the Insurer in the Box above
Note:
(i) Noperson shall act as an insurance agent for more than one life
insurer, one general insurer, one health insurer and one of each of
other mono-line insurers
(ü) Any person who acts as an insurance agent in contravention of the
provisions of this Act, shall be liable to a penalty which may extend to
ten thousand rupees
(iii) Attach Separate Application Form for each of the Insurance
Organisation with whom you seek to obtain Appointment and submit
all the Application Forms to your current insurer only.
APPLICATION FOR APPOINTMENT TO ACT AS AN INSURANCE AGENT
(With a Life Insurer OR General Insurer OR Health Insurer) for the FIRST
TIME.
TO
ESIST.LKYACNTIALLere CASURANCE
(Nameof the Insurer), Paste self
attested
passport
Size
Photograph
DEAR SIRS,
Irequest that Appointment to act as an insurance agent of your insurance
Organisationmay be granted to me.
Ihereby declare that particulars given below are true and that the
APPOINTMENT for which Iapply will be used only by myself for soliciting or
procuring insurance business for your Insurance Organisation
(1) Name: sllAMNGRAI ltdlulMRI
(2)Title : State 1 if are Mr., 2 Mrs., 3 Miss:
(3) Father's/Husband's Name
(4) Full Address:
House
No
Street ANC lHAL - Ma SAUHT
Town
District PATNa
State
Pin Code 0uS2
Mobile
qq49q999
No
(5)Date of Birth: Day- Month-Year (d-d 2-U[AG) Attach Age proof
(6) Educational Qualifications. (Tick the right Box)
Class X Class XII Graduate Post Other
Graduate
(7) PAN CARD Number ACLPKGISR(attach Attested copy of the PAN
CARD)
() ive particulars of pass in pre-recruitment test conducted by the Insurance
Institute of lndia or anyexamination body:
Name of Examination
Body:
Candidale's Name: SATYGNRA KUqaR
Candidate's Number:
Centre of Examination
Name of the Exam
passed
Date of Passing L6lb-202 (Day- Month-Year)
Note Attach certificate issued by the examining
body
9, I declare that---
a) Ihave not been found to be of unsound mind by a court of competent
jurisdiction;
b) Ihave not been found guilty of criminal misappropriation or criminal breach
of trust or cheating or forgery or an abetment 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, dishonestly or mis-representation against an insurer
or an insured,
d) Ihave not violated the Code of Conduct specified under Clause 7 of the
IRDAI (Appointment of Insurance agents) Guidelines, 2015.
Place YeLM Yours faithfully,
Date: u<oal204 Signature of applicant
Notes and Instructions
a) The application should be filled in, as far as possible, in Hindi language or
English language.
b Any correction or alteration made in any answer to the questions in the
application should be initialled by the applicant.
c An applicant must be at least 18 years of age on the date of the application
ifrequired the applicant shall furnish proof of age
d An applicant shall furnish the proof of pass in the Insurance exarmination
conducted by the Insurance Institute of India, Mumbai or an examination
body approved by the Insurance Regulatory and Development Authority of
India. along with the application.
e 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 () Cessation Certificate if any, that is held by
the Agent
Note to the Insurer:
(1) The applicant should be provided with an acknowledgment for the receipt
of the Agency Application form
(2) The details in the application form should be verified with the data available
with the insurer and the application form with due authentication should be
forwarded to the insurer with whom the applicant is seeking Agency within
15days of the receipt of the application form from the applicant. Acopy of
the forwarding letter should be sent to the applicant for his records.
(3)The designated official of the Insurer should ensure that under no
circumstances, there is a delay in forwarding the application fom to the
concerned insurer.
(4) The applicant shall ascertain from the Insurer to whom he has submited
the Agency Application form on the status of the Agency application
submitted by him.
