FORM-IRDA-17 AF
Reg [3(2)(C)]
APPLICATION FORMAT FOR GRANT OF MODIFIED LICENSE
INDIVIDUAL SURVEYOR
Important Instructions:
Any change in the information submitted to the authority must be informed to the authority within 15 days from date of the change, attach copies of documents as proof
Name
Name of Firm/Company ( wherever applicable)……….
Remarks ……………………………..
SLANO…………. Expiry date…………. Membership ID No……….. level of Membership…………….
Present Address :
Address 1: ………………………
Address 2: ………………………
Address 3: ………………………
City/Town/Village : ………
District: ………………………….
State: …………………..
Country:………………
Pincode: ………………
Remarks:……………………….
Change in Licensee Name
Incorporation of Sole Proprietary firm’s Name :
Name of Firm : ………………………
Remarks:……………………………..
Grant of Additional Departments :
Deptt.
Fire
Marine cargo
Marine Hull
Engg.
Motor
Misc
Crop Insurance
LOP
Select
Swapping of Departments :
Select
Current Department
Select New Department
License category(As per categorization)
Remarks: ………………………….. ( should we delete this as we are removing the restriction in departments)
Correction in the license already issued ( where there is a typrographical error in the license issued):
Change in level of Membership allotted by the Institute
From ……… To……….( Attach soft copy of Membership certificate issued by the Institute indicating such change/s and reasons thereof)
Change in Personal information :
Phone No.(Res) …………………
Phone No. (Office): ………………..
Mobile No. ……………………
e-mail: ………………………………
Alternate e-mail: …………………………
Remarks: …………………………
Signature of the applicant
Place….
Date…..