ANNEXURE 1
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 of 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 STDCode_____________ 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 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 examiner ____OR
(f) Are you an employee of a Medical Examiner?___ If your answer is ‘YES’ to any of
the above please give the following particulars about his/her applicable :
Name__________________________________Designation__________________
Relationship with you_________________ Agency Code No. _________________
Officer under which he/she works_________ Date of cessation of Agency_______ Name
of the Development Officer:______________________ Code 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 is 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 Expiry ____________
otherwise 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 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 whatsoever, I shall return my
Appointment letter and I 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__________ Signature of the Applicant
Signed in my presence
__________________
(Signature of Witness)
Name, Designation and Address
___________________________
________________________
REPORT OF THE DEVELOPMENT OFFICER /CLIA
1) (a) Is the applicant related to
i) Yourself?
ii) Any other employee of the Corporation?
iii) Medical Examiner?
iv) Any existing or ex-agent of the Corporation within the area of the Division
( Write ‘Yes’ or ‘No’)
b) If the answer to any of the question under (a) is ‘Yes’ , please give following further
information about the person to whom the applicant is related.
Name:________________________________ Designation
:________________________ Territory: _____________________________
Relationship: ________________________ (c) Is the applicant employed with a
Medical examiner of the Corporation? Yes/No If ‘Yes’ give details of the
the Medical Examiner ________________________________ (d) Whether any
other family member is working as Agent with any other insurer? Yes/No If ‘Yes’
specify ______________________________________________
2) Are you satisfied that the applicant would be able to absorb the Agency Training and
conduct the Agent on his/her own? ____________________________
3)(a) Will the applicant work for the Corporation (i) Full time or (ii)Part-
time?_______________ (b) If part time, in what other business or activities is he
engaged and what is the nature of his duties?
_______________________________________________________________________
(c)What is his approximate income from other business according to your information?
______ (4) Place or area in which the applicant will do business
________________________________ (5) Was he ever in the insurance trade, directly
or indirectly ? ___________________________ (6) Source from which application was
secured ____________________________________ (7) How long do you know the
applicant personally? __________________________________ (8) Give particulars of
apparent bodily defect or deformity______________________________ (9) Any other
particulars such as education, social background, character, financial stability ,etc.
_______________________________________________________________________
I do hereby declare that the foregoing statements and answers have been given after
due enquiries and are to the best of my knowledge and belief true and complete.
(SIGNATURE OF DEV.OFFICER/CLIA)
Place:___________________ Name: ___________________
Date :___________________ Code No: __________________
Preliminary Interviews by Sr./Branch Manger
(1) Are you satisfied that the applicant is not related to the Development Officer, any
employee of the Corporation , any Medical Examiner and /or another agent or Ex-
Agent?
________________________________________________________________________
(2) Do you think, in your judgement the applicant would be able to absorb agency
training and conduct the agency on his/her own?
________________________________________________________________________
(3) Any other remarks / observation
________________________________________________
_______________________________________________________________________
Date : _______________ Signature of the Sr./ Branch Manager
Branch
_______________________
______________________________________________________________________
Interview by the Appointing Authority on : _______________________________
Remarks :
Signature of the Appointing Authority
Designated official
(Marketing Manager )
List of documents submitted ( Please indicate by tick mark)- (For New
Agents)
1.Age Proof ( Only standard Age Proof to be submitted):
1.Matriculation Certificate
2.Passport
3.Birth Certificate
4. Any other ( specify)
2.Qualification Proof
1.Matriculation Certificate No.
2. HSC No.
3 .Degree Certificate
4. Any other ( specify)
3.Address Proof
1.Aadhar Card
2. Ration Card
3.Voters Id
4.Any other ( specify)
4. PAN Card
5. Bank Account Details
1. Cancelled cheque leaf OR
2. First page of Bank pass book/Bank statement
Signature of the Agent
