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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY

FORM - IRDA – 1 – AF (Regulation 3(g))

APPLICATION FROM A FIRM OR COMPANY FOR A LICENCE TO ACT AS A SURVEYOR/ LOSS ASSESSOR

To

Insurance Regulatory and Development Authority

Gate No. 3, First Floor, Jeevan Tara Bldg.

5, Parliament Street, New Delhi-110 001.

Tel. 3364711.

Dear Sir,

It is requested that a licence to act as a Surveyor/Loss Assessor may be granted to our Firm/ Company for the following classes.

Depts

Fire

Mrn Cargo

Mrn Hull

Engg.

Motor

Misc.

LOP

Please tick

1.

The receipt No. ……………dated………..from…………showing payment of fees of Rs. ____ is enclosed.

2.

It is hereby declare that-

(i)

no person of our Company/ Firm has been found to be of unsound mind by a Court of competent jurisdiction;

(ii)

no person of our Company/ Firm has been found guilty of criminal misappropriation or criminal breach of trust, or cheating or forgery, or an abatement of or attempt to commit any such offence by a Court of competent jurisdiction;

(iii)

no person of our Company/ Firm has 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 proceedings relating to any policy of insurance or the winding up of an insurance company or in the course of an investigation of the affairs of an insurers; and

(iv)

no person of our Company/ Firm is a minor.

(v)

no person(s) of our Company/ Firm shall violate the code of conduct specified by the regulations made by the Authority.

(vi)

all person(s) of our Company/ Firm possess the requisite qualifications and practical training as specified by the regulations made by the Authority.

(vii)

all persons of our Company/ Firm have passed such examination as specified by the regulations made by the Authority.

Explanation: “Person” means a director of the company/ partner of a firm/ employee of a company/ firm who can carry out the work of Surveyor and Loss Assessor.

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