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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY - page 19 / 28

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10. Experience:

a) Whether any of the new persons of the firm/ new directors of the company was employed with any insurance company (If so, give details): ____________    

b) Job Experience of new persons of the firm/ new directors of the company (if applicable) in previous employment other than insurance surveyor, if any: ___

c) Details of other business/ employment: _______________

I, ……………………………. solemnly declare and confirm that the particulars given above are true to the best of my knowledge and belief.

Signature:  ___________________________

Name: _________________________________

Date: _________________________________

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