INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA, HYDERABAD

APPLICATION FOR RECRUITMENT TO THE POST OF ASSISTANT MANAGER

PART I

Recent passport size

photograph
Post applied for___________________________________
Specialization applied for __________________________

(A) Personal details

S. Details
No
1 Name (In Block Letters)
2 Father’s name
3 Nationality
4 Religion to which you belong to
5 Date of Birth/Age
6 Mother Tongue
7 Present Residential Address with Pin code

8 Permanent Residential Address & Pin code

9 Sex (Male/Female)
10 Marital status (Single/Married/Divorced)
11 Telephone No. / Mobile No.
12 E-mail id
13 Whether belongs to SC/ST Category?
14 (i) Whether belongs to OBC category? (i)
(ii) If yes, whether belongs to “Creamy (ii)
layer”?
15 (i) Whether belongs to PWD (Persons with (i)
Disability) category?
(ii) If yes, mention the % of disability (ii)
16 (i) Whether belongs to Ex- Servicemen (i)
category?
(ii) If yes, date of discharge from service (ii)
17 (i) Organization in which working (i)
(ii) Address (ii)
(iii) Tel. No.
(iii)
18 Languages known Language (Read, R W S
Write, Speak)
Mark ‘Y’ or ‘N’
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 1.
2.
3.

(B) Qualifications
1. Academic Qualifications (Graduation onwards):
Examination University/ Year of Duration Subjects Percentage of
passed Institute Passing of Marks/CGPA/
/Board Course Division

2. Professional qualifications:
Examination University/ Year of Duration Subjects Percentage of
passed Institute Passing of Marks/CGPA/
/Board Course Division

(C) Service details

(i) Details of present employment held:

Sl. No Details

1 (i) Post held (i)

(ii) Designation (ii)
2 (i) Total no. of years of service (i)
(ii) No. of years in the present post (ii)
3 Present Pay scale

4 Present Basic pay, Grade pay/Grade

Allowance, if any (Pl. attach pay slip)
5 Experience in different areas/fields of working:
Department Job profile No. of years

1.

2.

3.

4.

2
(ii) Details of previous employment:

Office/Institute/ Post/Desi Period Nature of Scale of Gross

Organization gnation Appointment Pay salary
held and job and and
From To profile Basic Net
p a y & Grade salary
Pay/Gr.
Allowance, if
any

(iii) Have you ever been on deputation during your service to any organization including IRDAI?

Office/ Post Held Period Scale of Pay Nature of duties

Organization On and
deputation Basic p a y / P a y
Date of Date of
Band & Grade Pay
deputation repatriation

(iv) For IRDAI staff applicants:

Sl. No Details

1 Date of joining IRDAI

2 Details of service in IRDAI

Designation From To Department

(i)

(ii)

3
(D) Training

Have you in the past attended any specialized training programme?

Sl. No Name of the Institute Period of Details of Training course

Training undergone
1

(E) Other information

Sl. No Details
1 How do you consider your level of proficiency in
Insurance/Financial services?
Specify in terms of Average or Advanced
2 How do you consider your level of proficiency in
computer skills?
Specify in terms of Average or Advanced.
3 Has any Vigilance case been instituted against you?
Pl. furnish details (including those cases disposed off)
4 Any other relevant information, which you wish to
furnish

(F) Suitability

Please state briefly how you

find yourself best suitable for
the post applied for

(G) References (of Officers holding position 2 steps above the cadre of the
applicant)

4
Sl. Name Designation Address Contact Nos.
No

1.

2.

DECLARATION

1. I hereby declare that the all the statements made in this application are true, complete
and correct to the best of my knowledge and belief.
2. I declare that
a) I have not been, at any time, convicted by a court in India for any offence
involving moral turpitude.
b) No proceedings in respect of an offence alleged to have been committed by me
are pending before a criminal court in India.
c) No warrant or summons for the appearance, or a warrant for arresting me has
been issued by a court under any law for the time being in force or that an order
prohibiting me from departure from India has been issued by any such court.
2. I understand that any incorrect information furnished by me is found to be false or that
does not satisfy the eligibility criteria will lead to my disqualification from the selection
process and my candidature/appointment is liable to be cancelled / terminated.

3. I agree and declare that my admission to the written examination/interview is strictly

provisional. The mere fact that the call letter for written examination/interview has
been issued to me does not imply that my candidature has been finally cleared by
IRDAI and further it does not entitle me for appointment in IRDAI unless an
appointment letter is issued to me.

4. I understand and agree that in case of any selection process violation by me, I will not be
allowed to appear in any IRDAI recruitment process in the future. Further, I understand
and agree that if such instances go undetected during the current selection process but
are detected subsequently, such disqualification will take place with retrospective effect.

5
Date: (Signature of the Applicant)
Place:

Encl: Self attested copies of all certificates pertaining to the following are enclosed:

(i) Date of birth

(ii) Educational qualifications

(iii) Marks sheets (from Graduation onwards)

(iv) Professional qualifications

(v) Caste certificate, Disability certificate etc. (where applicable)

Part II

Certification from Organization where the applicant is presently working

1. The service particulars given by the applicant are verified with reference to his
Service records maintained with us and found to be correct.

2. (a) There are no vigilance/non vigilance/Miscellaneous cases pending against

the applicant in the records maintained by us.
(b) Details of vigilance/Miscellaneous cases filed against the applicant and
disposed off in the past:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

(Pl. tick the appropriate column and furnish information where necessary)
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 3. Terms of relief, if the applicant is selected for appointment in IRDAI -
_______________________________________________________________.

Date: (Signature of the Competent Authority)

Place: (Office seal)

PROFORMA – I

DISABILITY CERTIFICATE

NAME & ADDRESS OF THE INSTITUTE/HOSPITAL

Certificate No_________________ Date:

Recent Photograph
of the candidate
showing the
disability duly
attested by the
Chairperson of the
Medical Board

This is certified that Shri/Smt./Kum. ...............................son/wife/daughter of

Shri.......................................... age ..........sex ............ identification
mark(s) ........................ has appeared before us and we observe that he/she is suffering
from permanent disability of following category:

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A. Loco motor or Cerebral Palsy:

(i) BL— Both legs affected but not arms

(ii) BA—Both arms affected (a) Impaired reach
(b) Weakness of grip

(iii) BLA—Both legs and both arms affected

(iv) OL — One leg affected (right or left) (a) Impaired reach

(b) Weakness of grip
(c) Ataxic
(v) OA — One arm affected (a) Impaired reach
(b) Weakness of grip
(c) Ataxic
(vi) BH—Stiff back and hips (cannot sit or stoop)

(vii) MW—Muscular weakness and limited physical endurance.

B. Blindness or Low Vision:

(i) B—Blind
(ii) PB—Partially blind

C. Hearing impairment:

(i) D—Deaf
(ii) PD—Partially deaf
(Delete the category whichever is not applicable)

2. This condition is progressive/non-progressive/likely to improve/not likely to improve.

Reassessment of this case is not recommended/is recommended after a period
of ................years ............................... months.*
3. Percentage of disability in his/her case is....................... Percent.

4. Shri/Smt./Kum. ...................................... Meets the following physical requirements for

discharge of his/her duties:—

(i) F—Can perform work by manipulating with fingers. Yes/No

(ii) PP—Can perform work by pulling and pushing. Yes/No
(iii) L—Can perform work by lifting. Yes/No
(iv) KC—Can perform work by kneeling and crouching. Yes/No
(v) B—Can perform work by bending. Yes/No
(vi) S—Can perform work by sitting. Yes/No
(vii) ST—Can perform work by standing. Yes/No
(viii) W—Can perform work by walking. Yes/No
(ix) SE—Can perform work by seeing. Yes/No
(x) H—Can perform work by hearing/speaking. Yes/No
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 (xi) RW—Can perform work by reading and writing. Yes/No

(Dr.......................) (Dr......................) (Dr. ..................)

Member Member
Chairman
Medical Board Medical Board Medical Board

Countersigned by the Medical Superintendent/CMO/Head of Hospital (With seal)

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 PROFORMA - II

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES

This is to certify that Shri/Smt./Kumari/_____________________son/daughter

of________________of Village/town____________________ in
District/Division_____________________ in the State/Union Territory
_____________belongs to the _____________________community which is
recognized as a backward class under the Government of India, Ministry of Social
Justice and Empowerment’s Resolution No.
__________________________________________________ dated
_______________*. Shri/Smt./Kumari_______________________ and/or his/her
family ordinary reside(s) in the __________ District/Division of
the_______________________ State/Union Territory. This is also to certify that he/she
does not belong to the persons/sections (Creamy Layer) mentioned in column 3 of the
Schedule to the Government of India, Department of Personnel & Training O.M.
No.36012/22/93-Estt(SCT) dated 8.09.1993**.

District Magistrate,
Deputy Commissioner, etc.
Dated

Seal

* The authority issuing the certificate may have to mention the details of Resolution of
Government of India, in which the caste of the candidate is mentioned as OBC.

** As amended from time to time.

Note:- The term “ordinarily” used here will have the same meaning as in Section 20 of
the Representation of the People Act, 1950.

Note: Caste validity certificate in original, from the appropriate authorities of the
state/union territory from which the caste certificate was issued along with self-attested
Photostat copy is to be submitted at the time of interview.

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 Form of undertaking to be submitted by the OBC candidate

(in addition to the Community Certificate)

UNDERTAKING

I, ….…………………………….. Son/daughter of Shri …………………. Resident of

…………………………..village/town/city………………….district……………………….…
State/UT ……………… hereby declare that I belong to the………………..community
which is recognized as a backward class by the Government of India for the purpose of
reservation in services as per orders contained in Department of Personnel and Training
Office Memorandum No. 36012/22/93-Estt.(SCT) dated 08.09.1993. It is also declared
that I do not belong to Persons/sections (Creamy Layer) mentioned in column 3 of the
Schedule to the above referred Office Memorandum dated 08.9.1993, O.M. No.
36033/3/2004-Estt.(Res.) dated 9th March, 2004 and O.M. No. 36033/3/2004-Estt.(Res.)
dated 14th October, 2008 and O.M. No.36033/1/2013-Estt.(Res.) dated 27 th May, 2013.

Signature of Candidate
Place:

Dated:

PROFORMA - III
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 FORM OF SCHEDULED CASTE/ TRIBE CERTIFICATE

This is to certify that Shri/Shrimati/Kumari*..................................................

Son/daughter* of .................................................... Of
village/town* ................................................. in
District/Division* ........................................... of the State/Union Territory* ......................
belongs to the.......................... Caste/Tribe* which is recognized as a Scheduled
Caste/Scheduled Tribe* under:—
* The Constitution (Scheduled Castes) Order, 1950
* The Constitution scheduled Tribes) Order, 1950
* The Constitution (Scheduled Castes) Union Territories Order, 1951
* The Constitution (Scheduled Tribes) Union Territories Order, 1951
[as amended by the Scheduled Castes and Scheduled Tribes List (Modification) Order,
1956; the Bombay Reorganization Act, 1960, the Punjab Reorganization Act, 1966, the
State of Himachal Pradesh Act, 1970, the North Eastern Areas (Reorganization) Act,
1971, the Scheduled Castes and Scheduled Tribes Order (Amendment) Act, 1976., the
State of Mizoram Act, 1986, the State of Arunachal Pradesh Act, 1986 and the Goa,
Daman and Diu (Reorganization) Act, 1987.]

* The Constitution (Jammu and Kashmir) Scheduled Castes Order, 1956

* The Constitution (Andaman and Nicobar Islands) Scheduled Tribes Order, 1959 as
amended by the Scheduled Castes and Scheduled Tribes Order (Amendment) Act,
1976 @ The Constitution (Dadar and Nagar Haveli) Scheduled Castes Order, 1962

* The Constitution (Dadar and Nagar Haveli) Scheduled Tribes Order, 1962
* The Constitution (Pondicherry) Scheduled Castes Order, 1964
* The Constitution (Uttar Pradesh) Scheduled Tribes Order, 1967
* The Constitution (Goa, Daman and Diu) Scheduled Castes Order, 1968
* The Constitution (Goa, Daman and Diu) Scheduled Tribes Order, 1968
* The Constitution (Nagaland) Scheduled Tribes Order, 1970
* The Constitution (Sikkim) Scheduled Castes Order, 1978

2. Shri/Shrimati*/Kumari*________________________and/or* his/her* family ordinarily

reside(s) in Village/town*__________________________ of
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____________________________ District/Division* of the State/Union Territory of
_______________

Signature______________

Designation________________

Signature of the Competent Authority @

Place_____________

Date______________

*Please delete the words which are not applicable.

Note: The term “Ordinarily resides” used here will have the same meaning as in Section
20 of the Representation of the Peoples Act, 1950.

@ Authorities who are competent to issue the Scheduled Caste/Tribe certificate are as
follows:

District Magistrate / Additional District Magistrate / Collector/Deputy Commissioner/

Deputy Collector/ First Class Stipendiary Magistrate/ Sub-Divisional Magistrate/ Taluka
Magistrate/Executive Magistrate/Extra Assistant Commissioner (Not below the rank of
First Class Stipendiary Magistrate).

Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency

Magistrate/ Revenue Officer not below the rank of Tehsildar.

Sub-Divisional Officer of the area where the candidate and/or his family normally
resides.

In so far as the Scheduled Tribes community of Tamil Nadu is concerned, the Certificate
given by the Revenue Divisional Officer instead of Tehsildar will only be accepted.

Note: Caste validity certificate in original, from the appropriate authorities of the
state/union territory from which the caste certificate was issued along with self-attested
Photostat copy is to be submitted at the time of interview.

PROFORMA – IV

CERTIFICATE TO BE PRODUCED BY SERVING/RETIRED/RELEASED ARMED

13
 FORCES PERSONNEL FOR AVAILING THE AGE CONCESSION

A. Form of Certificate applicable for Released/Retired Personnel

It is certified that No.....................

Rank.....................Name..........................................whose date of birth is.....................
has rendered service from..................... to..................... in Army/Navy/Air Force.

2. He has been released from military services:

#a) on completion of assignment otherwise than

1(i) by way of dismissal, or
2(ii) by way of discharge on account of misconduct or inefficiency, or
(iii) on his own request, but without earning his pension, or
(iv) he has not been transferred to the reserve pending such release
#b) on account of physical disability attributable to Military Service.
#c) on invalidment after putting in at least five years of Military service

3. He is covered under the definition of Ex-Serviceman (Re-employment in Central Civil

Services and Posts) Rules, 1979 as amended from time to time

Signature, Name and Designation

of the Competent Authority**
SEAL
Place: ..........................
Date: ...........................

# Delete the paragraph which is not applicable.

B. Form of Certificate for Serving Personnel

(Applicable for serving personnel who are due to be released within one year)

It is certified that No. ……………Rank……….Name………. is serving in the

Army/Navy/Air Force from……………………

2. He is due for release retirement on completion of his specific period of assignment

on……………..
#a) on completion of assignment otherwise than
1(i) by way of dismissal, or
2(ii) by way of discharge on account of misconduct or inefficiency, or
(iii) on his own request, but without earning his pension, or
(iv) he has not been transferred to the reserve pending such release
14
#b) on account of physical disability attributable to Military Service.
#c) on invalidment after putting in at least five years of Military service

3. No disciplinary case is pending against him.

Signature, Name and Designation

of the Competent Authority**
SEAL
Place: ..........................

Date: ...........................

# Delete the paragraph which is not applicable.

** Authorities who are competent to issue certificate to Armed Forces Personnel for
availing Age concessions are as follows:

(a) In case of Commissioned Officers including ECOs/SSCOs.

Army - Military Secretary Branch, Army Hqrs., New Delhi
Navy - Directorate of Personnel, Naval Hqrs., New Delhi
Air Force - Directorate of Personnel Officers, Air Hqrs., New Delhi

(b) In case of JCOs/ORs and equivalent of the Navy and Air Force.
Army - By various Regimental Record Offices
Navy - BABS, Mumbai
Air Force - Air Force Records, New Delhi

Candidate (Serving Personnel) furnishing Certificate B as above will have to give

the following undertaking:

Undertaking to be given by serving Armed Force personnel who are due to be

released within one year

I understand that if selected on the basis of the recruitment/Examination to which this

application relates, my appointment will be subject to my producing documentary
evidence to the satisfaction of the appointing authority that I have been duly
released/retired/discharged from the Armed Forces and that I am entitled to the benefits
admissible to Ex-Servicemen in terms of the Ex-Servicemen (Re-employment in Central
Civil Service and Posts) Rules, 1979, as amended from time to time.
15
Place: Signature and Name of Candidate

Date :

FORM OF UNDERTAKING TO BE GIVEN BY CANDIDATES APPLYING

FOR CIVIL POSTS UNDER EX-SERVICEMEN CATEGORY

16
I understand that if selected on the basis of the recruitment/Examination to which this
application relates, my appointment will be subject to my producing documentary
evidence to the satisfaction of the appointing authority that I have been duly
released/retired/discharged from the Armed Forces and that I am entitled to the benefits
admissible to Ex-Servicemen in terms of the Ex-Servicemen (Re-employment in Central
Civil Services and Posts) Rules, 1979, as amended from time to time.

2. I also understand that I shall not be eligible to be appointed to a vacancy reserved for
Ex-servicemen in regard to the recruitment covered by this examination, if I have at any
time prior to such appointment, secured any employment on the civil side (including
Public Sector Undertaking, Autonomous Bodies/Statutory Bodies, Nationalized Banks,
etc.) by availing of the concession of reservation of vacancies admissible to Ex-
servicemen.

Signature of Candidate

Place:

Date:

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