Form A

FORM -I-B
APPLICATION OF AN EXISTING INSURANCE AGENT FOR APPOINTMENT TO

ACT AS COMPOSITE INSURANCE AGENT WITH ANOTHER INSURER (LIFE OR
GENREAL OR HEALTH INSURANCE or MONO-LINE INSURANCE)
NAME OF INSURANCE AGENT _____________________________
DETAILS OF THE INSURANCE AGENCY HELD (Past & Present)

Name of the Agency code Date of Date of cessation Reason for
Insurer Number Appointment of Agency cessation of
as agent agency
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 Insurance Company
General Insurance Company
Health Insurance Company
Other Mono-Line Insurance Company
** Mention name of the Insurance company in the Box above
Note:
(i) No person 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
(ii) 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 Company 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
----------------------------------------- (Name of the Insurance Company),
-----------------------------------------,
----------------------------------------
----------------------------------------.
DEAR SIRS,
I request that Appointment to act as an insurance agent of your insurance company 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 Company
(1) Name: [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
(2)Title : State 1 if are Mr., 2 Mrs., 3 Miss: [ ]
11
(3) Father's/Husband's Name [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
(4) Full Address:
House No
Street
Town
District
State
Pin Code
Mobile No
(5) Date of Birth: Day- Month-Year [ ][ ]-[ ] [ ]-[ ][ ][ ][ ] Attach Age proof
(6) Educational Qualifications. (Tick the right Box)
Class X Class XII Graduate Post Graduate Other
(7) PAN CARD Number ________________ (attach Attested copy of the PAN CARD)
(8) Give 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)
Note Attach certificate issued by the examining body
9. 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 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.
Place Yours faithfully,
Date: 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. If required the applicant
shall furnish proof of age.
d) An applicant shall furnish the proof of pass in the Insurance examination 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.
12
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 15 days of the receipt of the application
form from the applicant. A copy 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 form to the concerned insurer.
(4) The applicant shall ascertain from the Insurer to whom he has submitted the Agency
Application form or from the insurers with whom he is seeking Agency Appointment on the
status of the Agency application submitted by him.
13

Form A

Uploaded by

Copyright:

Available Formats

Form A

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Form A

Uploaded by

Copyright:

Available Formats

FORM -I-B

APPLICATION OF AN EXISTING INSURANCE AGENT FOR APPOINTMENT TO

DETAILS OF THE INSURANCE AGENCY HELD (Past & Present)

Note If Agency is currently in-force with an insurer mention “INFORCE” in the

APPLICATION FOR APPOINTMENT TO ACT AS AN INSURANCE AGENT

Place Yours faithfully,

Date: Signature of applicant

Notes and Instructions

You might also like