FORM - IRDA - 1 - AF
[See Regulation 3(1)]
APPLICATION FOR A LICENCE TO ACT AS SURVEYOR AND LOSS ASSESSOR
(INDIVIDUAL)
Checklist
Please ensure the following:
1) To enclose a copy of the Student Membership Certificate issued by the Institute
2) To make online payment of fees ( as mentioned in the Regulations) through “ NET BANKING /DEMAND DRAFT/NEFT/RTGS” during application submission.
3) Have scanned copies ready of Degree/ Diploma attested by Notary/ Magistrate.
4) To attach scanned copy of affidavit duly Notarized against S.No. 2 of the application form.
5) To enclose attested and scanned documents in response to Q. No.’s 4, 8, 9, 10 & 11. The answers to which are a must.
6) To attach a recent scanned copy of passport size photograph along with the application form.
7) Send physical copies of application, uploaded documents and self addressed envelope of 4.5”X10 with Rs.40 postage stamp to IRDA. These are mandatory for grant of license.
Notes: Read with Regulation 3
1. The attention of the applicant is drawn to Section 102 of the Insurance Act 1938, which provides that whoever in any document required for the purpose of any of the provisions of the Act, rules or regulations made thereunder, fails to furnish the same shall be liable to a penalty not exceeding Rs. 5 lakhs for each such failure and punishable with fine.
2. An individual can apply for only one licence, which will entitle him to act as a Surveyor and Loss Assessor for any insurer.
3. Any correction or alteration made in answer to the questions in the application should be initiated by the applicant.
4. An applicant must be at least 18 (eighteen) years of age on the date of submission of the application. In the case of any applicant declaring him at is 18 years the exact date of birth of falling in the year or birth should be stated against item 4 of the application. If require the applicant shall furnish proof age.
5. A notification will be sent to the applicant on successful submission of the application form.
6. Any change in the information submitted to the authority must be informed to the authority within 15 days from date of the change.
7. As the licence is issued bilingual viz. Hindi and English, the applicant may like to indicate how he spells his name in Hindi. It is, therefore, advised that the name and address may be written.
1. I student member of the Institute, request that a license to act as a Surveyor and Loss Assessor may be granted to me for the following class/department
Dept
Fire
Marine cargo
Marine Hull
Engg
Motor
Misc
Crop Insurance
LOP
Please tick
Student Membership Details… ( to upload soft copy of the Membership Certificate and ID card issued by the Institute)
2. I hereby declare that
i) I have not been found to be of unsound mind by a Court of competent jurisdiction.
ii) I have not been found guilty of criminal misappropriation or criminal breach of trust or cheating or forgery or of abetment or attempt to commit any such offence by a Court of Competent Jurisdiction.
iii) I have not been found guilty of or to have knowingly participated in or connived at any fraud/dishonesty or misrepresentation against an insurer or an insured in the course of any judicial proceeding relating to any policy of insurance or the winding up of an insurance company.
iv) I shall not violate the code of conduct specified by the regulations made by the Authority.
v) I possess the requisite qualifications and practical training as specified by the regulations made by the Authority.
vi) I have passed such examination as specified by the regulations made by the Authority.
3. I also declare that the particulars given below are true:
a. Full Name (Shri/Smt/Kum)[in English & Hindi) ………………………………..
b. Father/Husband's Name ………………………………..
c. Present address [in English & Hindi] Address1 ……………………………….. Address2 ……………………………….. Address3 ……………………………….. City/Town/Village ……………………………….. District ……………………………….. State ……………………………….. Country ………………………………..
Pincode ………………………………..
d. Permanent address
Address1 ……………………………….. Address2 ……………………………….. Address3 ……………………………….. City/Town/Village ……………………………….. District ……………………………….. State ……………………………….. Country ………………………………..
Pincode ………………………………..
4. Qualification
a) Academic / Professional ………………………………..
b) Insurance ………………………………..
c) Training Attended ……………………………….. (Nature – Duration for all of the above)
5. Communication
Phone Office
Phone Res.
Fax
Mobile
Email ID
Alternate Email ID
6. Date of Birth ………………………………..
7. Sole Proprietor (Name if applicable) ………………………………..
8. Practical Training Details (Please enclose the Training Completion Certificate obtained from the surveyor/ survey firm)
9. Experience Details:
a) Whether the applicant was employed with any insurance company:
b) Job Experience in previous employment other than insurance surveyor, if any:
c) Details of other business/ employment:
10. Occupation status: Student Professional Business Employee Service Housewife Others …………
11. Employment details:( In chronological order of employment).
a) Whether applicant is currently employed? Yes/No ……………
b) If yes, provide details below and also attach scanned copy of NOC from employer
Name of Employer
Nature of Organization
Nature of Work
Period of employment
From Date
To Date
(Govt./Semi-govt/Private Firm, insurance company, surveyor firm, PSU, others)
(Insurance survey related, Others)
c) Details of any other business/profession carried out:
Name of Firm
Designation
Nature of Business
Name of the Surveyor/Surveyors' Firm
Departments allocated to surveyors/ Surveyor Firm
Level of Membership allotted to the Surveyor/ Survey Firm
Period of training undergone (Please mention dates)
Name of person(s) under whom training undertaken
Areas Covered
Result
12. Have you ever held a license to act as a surveyor and loss assessor? If Yes, please provide details: License No. ………………. Date Of Issue ………………. Expiry Date ……………….
13. Fee Payment: NET BANKING/DEMAND DRAFT/NEFT/RTGS
Fee applicable for all Surveyor categories
Category of surveyor and loss assessor based on the membership allotted by the Institute
Amount payable by individuals surveyor and Loss Assessor
Fellow member
10000
Associate Member
7500
Licentiate Member
5000
14. Declaration:
I solemnly declare and confirm that the particulars given above are true to the best of my knowledge and belief.
Signature of Applicant…………………………………