SERIAL No.

AGENCY MENTOR
APPLICATION FORM
VERSION - 3

HDFC Life -Version 3 - 17-01-2019

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 INSTRUCTIONS Serial No.
1. Please enter all the details called for in this Application Form.
2. All documents submitted need to be self attested.
3. Signature of the Agency Mentor and concerned reporting Manager (BDM/ASM/CH/ACH) required necessarily on all pages as specified.
4. All the above documents need to be attached along with the application form and the candidate Agency Application forms need to be
sent to the respective Branch ops / Central Agency Team / CAMs locations as per launching mail circulated from time to time.
CHECKLIST

THE DOCUMENTS REQUIRED ARE: Submitted

1. Permanent Account Number A copy of the PAN Card Yes No
2. Photo Identify Proof Yes No
3. Address Proof Yes No
4. 1 recent passport sized photograph Yes No
5. Degree of professional Education (in case professional educational qualification selected) or graduation proof Yes No
6. NEFT/ECS Mandate to be verified and signed& stamped by concerned Bank authority
(in case, cancelled cheque do not bear AM name printed thereon) Yes No
7. Cancelled Copy of Cheque
8. Occupation Proof Yes No
9. KYC Norms
A) For Company
• Copy of Certificate of Incorporation received from R.O.C Yes No
• Details of the Directors and DIN Number(Director Identification Number) Yes No
• Copy of MOA (Memorandum of Association) or Copy of AOA(Articles of Association) Yes No
• KYC Addendum of all active directors Yes No
B) For registered partnership firms
• Copy of registration of the partnership firm Yes No
• Copy of the deed of partnership entered into between the partners Yes No
• Copy of KYC Addendum of all Partners Yes No
10. Registration certificate, whichever applicable
• CST Registration Certificate Yes No
• VAT Registration Certificate, if applicable Yes No
• Good & Service Tax Registration Certificate, if applicable Yes No

11. Income Proof Yes No

• In case of Life / General Insurance Agents: Commission statement confirming Commission credits(OR)Business Proof confirming
minimum stipulated amount of Business done(OR) Club Membership Certificate of MDRT/COTITOT etc. from the Company.
• In case of CAs, Tax Consultants, CFAs, Advocate, ICWA, CS, CFP, Stoke broker, sub broker, NBFCs, others: Income Tax return of last
one year or financial report of last 3 years or Brokerage Statement or Commission Statement, Form 16 / Salary Slip / Business Proof
confirming minimum stipulated amount of business done of 10 Lacs in a year
• In case of Mutual Fund Distributor: Assets Under Management( AUM)- statement from Kaarvy/CAMs or from the Fund House.
• In case of Others: Income Tax return of last one year & Financial report of last 3 years /
Note:
• Photo identity proof, i.e.:, copy of voters ID, Driving Licensee, Passport, Pan Card, Bank Statement with photograph (last 6 months).
Ration Card with photograph,etc. as per KYC.
• Address proof i.e.: Adhaar Card, Passport, Driving License, Lease Agreement with Rent Receipt(not more than 3 months old),
Telephone bill (not more than 2 months old), Electricity Bill, Ration Card, Voter's ID etc.

_______________________________________ ____________________________________________
Name of the FLS / ACH / CH Signature of the FLS / ACH / CH
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 AGENCY APPLICATION FORM FOR AGENCY MENTOR
HDFC LIFE INSURANCE COMPANY LIMITED
Reg Office : 13th Floor, Lodha Excelus, Apollo Mills Compound, N. M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
CIN: L65110MH2000PLC128245

SERIAL No. Please

passport size
photograph
Important Guidelines: All the below mentioned fields are mandatory. Pelase mention N/A wherever not applicable (applicable
only if
individuals)
Type Entity: Individual Partnership Company others
Signature of Applicant
Tittle : Mr Mrs Miss M/s. (inside the box)

Personal details:

(1) (a.1) Full name: *As it appears on PAN Card/Bank statement. To be filled in BLOCK LETTERS only.
First Name N I K E T
Middle Name
Last Name C H O U D H A R Y
**(only for married females) In case of changes in the name post marriage, please mention maiden name here.

(b.1) Date of Birth: 2

D D
7 0M M
9 1Y 9Y Y8 Y3 (c) Gender Male Female
OR
(a.2) Name of Entity (In case not an Indivisual): M/S

(b.2) Full Name of Authorised/ Contact person:

(c.1) Date of Incorporation : D D M M Y Y Y Y

(2) *Father’s/Husband’s Full Name: R A J E N D R A K U M A R C H O U D H A R Y

*Mandatory only in case of individual
(3) Communication Address: (Attach proof for below mentioned address)
House/Flat No. 1 9 , Soc/buld Name N E H N I K E T
Street / Town : I N D R A N A G A R K A N K E R O A D
Sub District :R A N C H I
District:R A N C H I Pin Code: 8 3 4 0 0 8 State: J H A R K H A N D
*Mobile no.: 7 5 4 9 1 7 8 5 5 5 Telephone No (R):
WITH STD CODE
*Email ID (Mandatory):

(4) Permanent Address: (if not same as above)

House/Flat No. , Soc/buld Name
Street / Town
Sub District :
District: Pin Code: State:
*Mobile no.: Telephone No (R):
*Is your mobile no. registered under DND? Y/N # If Yes, Kindly get it de-activated to receive important SMS Alerts from us regularly
Note: All official communication would be sent to you only via your menioned email ID
(5) Marital Status: Single Married Divorced Widowed
(6) Nationality: I N D I A N
(7) Location : Rural Urban
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 Serial No.
(8) Educational Qualifications*. (Tick the right Box) (Attach self attested certificate)
1. Graduate 8. ICWA

2. Post grad & above 9. Bachelor of Law (LLB):

3. Chartered Accountancy (CA) 10. Bachelor of Management Studies (BMS)

4. Certified Financial Planner (CFP) 11. Company Secretary (CS)

5. Cost and Management Accountant (CMA) 12. Doctor

6. Bachelors in Banking and Insurance course (BBI) 13. Other Professional Degree (if any)
Please Specify
7. Bachelors of Financial Markets (BFM)
• *Mandatory: Proof required of professional degree
• In case of partnership / company, select educational qualification of any one partner / director

(9) *PAN CARD Number (Attach self attested copy of the PAN CARD) A K I P K 5 0 2 1 B /
TAN No.:
* PAN number is mandatory
Business details:
(10) a) In case of Individual:
1. Occupation:
I. Tax Consultants VI. Stock Brokers / Sub Brokers XII. Chartered Financial Analyst
II. Advocate VII. Chartered Accountants XIII. CS

III. CFP VIII. ICWA XIV. Financial Distributor

IV. Mutual Fund Distributors IX. Certified Financial Planner XV. Others BUSINESS
Please Specify
V. Life / General Insurance Experience X. NBFCs

b) In case of Partnership / Company / Others:

1. Annual Turnover for last Financial Year(in Lacs):

2. Nature of Services / Occupation :

3. Years in business: years

4. Total no. Of Employees (if any):

5. Are you registered Under MSMED 2006 (Micro,Small, Medium, Enterprises Development): Yes No

a. IF Yes, provide registration details :

6. VAT Registration (TIN) Number (if applicable):
7. CST Registration Number (if applicable):
8. Goods & Service Tax Registration Number (if applicable):
(11) Do you have any compliance / legal processing initiated / pending / orders passed with regards to any regulatory authority or
companies that you are associated with. Yes No
If yes, please provide details

(12) Are you a “Politically Exposed Person” [PEP]?

Please answer Yes or No
Definition of a “Politically Exposed Person”: A “Politically Exposed Person” is a person who performs important function for the state.
This would include individuals who have or have had positions of public trust such as government officials, senior executives of
government corporation, politicians, important political party officials, member of parliament, member of assembly, etc. and their
families and close associates.
In case of Partnership / company / others, PEP would be “ Yes” if any of the existing partner / director’s is exposed politically.

13) Whether Agency Mentor belongs to the Insurer Group Yes or No

14) Whether Agency Mentor is associated with Insurer's Distribution Partner Yes or No

15) Whether Agency Mentor is associated with Insurer's Distribution Partner's Group or Related Party Yes or No

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 Serial No.

Certificate of Undertaking

1. I Mr./Ms./Mrs. N I K E T C H O U D H A R Y
hereby declare that i do not have any of my relative* working either as an employee or as a FC with HDFC Life at the time of coding.
*Relative is defined as “spouse, dependent children or dependant step children whether residing with the Agency Mentor or not.

2. “I understand that HDFC Life shall communicate with me in connection with the agency, and any such communication will not be
classified as “Commercial Communication” under the TRAI regulation. I hereby agree to indemnify, defend and hold harmless HDFC
Life and its employees, respective directors, and assigns against any liability or loss that may occur due to complaints registered by
me with TRAI for receiving calls from or on behalf of HDFC Life.”

3. I hereby confirm that all the details of the Agency Mentor program including product credit premium calculation, Remuneration
structure, expectations from me as a Agency Mentor have been explained to me in detail and I have understood them clearly. I under-
stand that these payments would be calculated as per the prevailing structures and will be credited electronically to my accounts as
per the agreed timelines. I also appreciate fully that the parameters of the program are subject to change from to time and the same
would be communicated to me by the authorized officials as and when they happen through any medium.

I / We further confirm that all the details provided in the application form are true to the best of my knowledge and ability. I understand
that any discrepancy found in the facts provided by me would be treated as a serious lapse and would be dealt with as per company’s
Rules and Regulations. I/We understand that HDFC Life may request additional information to substantiate the details provided and the
same will be made available to the HDFC Life. I/We also understand that as an empanelled vendor I/we need to provide best quality
services.

___________________________________
Signature of Agency Mentor
Date: D D M M Y Y Y Y

Mapping Details

RANCHI - DIVERSION ROAD

*Branch Name: _________________________________________________________________________ Branch Code: 0 6 9
RANJIT SINGH
Immediate Reporting Manager (L1) name: _________________________________________________________________________

AREA BUSINESS MANAGER *Agency Code: 2 3 0 5 3 7

Designation: ________________________________ Signature :______________________

SAURABH AGRAWAL
Immediate Reporting Manager (L2) name: _________________________________________________________________________

AREA HEAD
Designation: _________________________________ *Agency Code: 2 1 2 3 1 5 Signature :______________________

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 Serial No.

TO be filled by HDFC Life sales Team

1. RANCHI - DIVERSION ROAD
HDFC Life Branch Name: ___________________________________________________________ Branch Code: 0 6 9

2. NIKET CHOUDHARY
Name of Agency Mentor: ________________________________________________________________________________

3. PERSONAL NETWORK
Source of Recruitment: _________________________________________________________________________________
SELF
Personal Network ______________________________________Others (Please specify) ____________________________

4. No. of Years agency mentor is in this city / town 0 4 0

5. Does Agency Mentor Have an Office: Yes No

If Yes, provider details:

1. Office Address: _____________________________________________________________________________________

1 9 , I N D I R A N A G A R , K A N K E R O A D
R A N C H I - 8 3 4 0 0 8
_____________________________________________________________________________________

_____________________________________________________________________________________

2. Office basic details:

1400
a). Size of office (in sq feet)____________

b). Other infrastructures

Desktop 0 5 Laptop 0 2 FAX 0 1 Printer 0 1

3. Contact no. of Office: 9 4 3 1 7 0 8 9 5 5
09
4. No. of Employees: ____________

IN CASE THE AGENCY MENTOR DOES NOT HAVE OFFICE THEN IS HE IS PLANNING TO OPEN AN OFFICE IN THE NEXT:

1 Month 2 Month 3 Month 4 Month, If other, pls. specify ____________________________________________

DESCRIBE BRIEFLY THE PROFILE OF THE AGENCY MENTOR

Mention AM’s earnings, Business potential and industry experience (manda tory Information)

08 Years
No of Month or Years
Industry Experience: ____________________________
25 Lacs
Earning (per annum): ___________________________
1.00 Cr.
Business Potential per annum: _____________________

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 MANDATE FOR AVAILING NEFT/ECS FACILITY FOR REMUNERATION FROM
HDFC LIFE INSURANCE COMPANY LIMITED (USER INSTITUTION)
(In terms of FORM No. E-5)

ECS NEFT Serial No. Date: D D M M Y Y Y Y

GENERAL DETAILS
* Name of Agency Mentor (as provided in the bank records)
N I K E T C H O U D H A R Y
* Agency Code (only if the Agency Mentor is already associated with HDFC Life)

BANK ACCOUNT DETAILS

*A) Name of the Bank: H D F C B A N K
*B) Account Number: 5 0 1 0 0 2 5 3 8 7 1 3 4 1
(As appearing on the cheque book)
*C) Name of the bank H D F C B A N K
Branch Address K A N K E R O A D
Telephone No. 7 5 4 9 1 7 8 5 5 5
*D) IFSC CODE (11-Digit code number of the bank and branch) H D F C 0 0 0 2 6 8 7
*E) MICR No. (9-Digit code number of the bank and branch) 8 3 4 2 4 0 0 0 7
*F) Type of the account (Only tick the correct one) S A V I N G S
Savings Current Cash Credit / Overdraft
G) Ledger and Ledger folio number
(In lieu of the bank certificate to be obtained as under, please attach a blank cancelled cheque or photocopy of a cheque for verification of the above particulars)
DECLARATION
1. I/We hereby declare that the particulars given above are correct and complete and no blanks have been left. If the transaction is delayed or not
effected at all or the credit is given to an incorrect account for reason of incomplete or incorrect information provided here, I/We would not hold HDFC
Life Insurance Company Limited (HDFC Life) or any of its associated a gents responsible.
2. I/We further undertake to refund any amount credited to my account either in excess or which is not due to me/us, at anytime due to any reason,
whether by HDFC Life or not.
3. I/We agree that the remuneration will be credited starting from the date that occurs after the date of this Mandate unless the Mandate is revoked and
issuance of relevant credit instruction from HDFC Life into the aforesaid account will be a valid discharge to HDFC Life.
4. l/We further confirm that I/We understand this mode as a method of payment introduced by Reserve Bank of India, which provides us an option to
collect our remuneration, as and when they become due directly through our bank accounts.
5. I/We further confirm that I/We understand, HDFC Life shall accomplish this by issuing the Payment instruction electronically through its banker /
agent to the Clearing Authority and the Clearing Authority would ensure credit to our specified bank account.
6. I/We further undertake to inform HDFC Life with an advance notice of 6 weeks, in case, l/We desire to change our bank details, due to any reason.
However, HDFC Life shall retain the right to accept this or reject the same in case the revised bank details are not enabled under this NEFT framework.
7. I/We further undertake to inform HDFC Life with an advance notice of 6 weeks, incase l/we decide to withdraw from this mode of payment.
8. By Furnishing this mandate, l/We revoke any mandate issued earlier for receiving credit of the remuneration.
SIGN HERE

DD/MM/YYYY
Date: _______________

RANCHI Signature of Account Holder/

Place: _______________ Stamp and sign of authorised signatory
Certified that the Bank Account Details, the Name of the Account Holder and the signatures furnished are correct as per our record.
SIGN HERE
DD/MM/YYYY
Date: _______________
Branch Stamp and date
RANCHI
Place: _______________
Stamp and Sign of Authorised Signatory

Declaration (to be filled in case of mismatch in name)

I have applied for an appointment with HDFC Life as Agency Mentor in the name of
. I declare that my name mentioned on the agency application
form & the documents is whereas the name mentioned
on my bank account is I hereby declare that both these
names belong to me. I shall indemnify HDFC Life and keep them free from any claims, damages, penalties, costs, charges, levies
whatsoever due to the representation done above by me.

Signature :
Date: D D M M Y Y Y Y
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