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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY

FORM - IRDA – 3 – AF (Regulation 5(f))

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

From

Name of the Applicant ………………………………………………………………………..

(In Block Letters)

Full Address:  ………………………………………………………………………………….

         …………………………………………………………………………………

(In Block Letters)

To

Insurance Regulatory and Development Authority

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

5, Parliament Street, New Delhi-110 001.

Tel. 3364711.

Licence No. …………… Department Allocated ………………….Category…………………

I.D. Card No. ………………….. Date of Expiry …………

Dear Sir,

It is requested that the above licence may be renewed for a further period of five years for the following classes of insurance.

Depts

Fire

Mrn Cargo

Mrn Hull

Engg.

Motor

Misc.

LOP

Please tick

2.

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

3.

It is hereby declared 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.

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