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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY - page 21 / 28

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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY

FORM - IRDA – 4 – AF (Regulation 5(a))

APPLICATION FOR RENEWAL OF A LICENCE TO ACT AS

SURVEYOR/ LOSS ASSESSOR

From :

Passport size Photo

(3+1)

Sh./Smt/Kumari                                 ------------------------------------

Name of Surveyor/Loss Assessor      ------------------------------------

(in Hindi & English)           -------------------------------------

Full Address           -------------------------------------

(in Hindi & English)           -------------------------------------

working as sole-proprietor of           -------------------------------------

To

Insurance Regulatory Authority

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

5, Parliament Street, New Delhi-110 001.

Tel. 3364711.

Licence No. --------------------------------Date of Expiry -------------------------------------

Depts. Allocated. ______________ Category____________ ID Card No.__________-

Dear Sir,

1.

I request that the above licence may be renewed for a further period of five years.

2.

I enclosed Demand Draft No. --------------------------Dated ----------------------------

on --------------------------------------------showing the payment of fee.

3.

I declare that since the date of my last application for licence (affidavit on two Rupees Stamp paper/ non judicial paper – duly notorised).

(i)

I have not been found to be 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 of an abetment of or attempt to commit any such offence by a Court of Competent jurisdiction and

(iii)

I have not been found guilty of or to have knowingly participated in or connived at any fraud/dishonesty or made any misrepresentation against an insurer or an insured in the course of any judicial proceeding relating to a policy of insurance or the winding up of any investigation of the affairs of an insurer, and

(iv)

My licence has not been cancelled at any time by the Controller of Insurance/ Insurance Regulatory and Development Authority.

(v)

I declare that I continue to hold the qualification on the basis of which my licence mentioned above was issued.

(vi)

An undertaking on performance report showing survey work done by me during the last 5 years of the validity period indicating total number of survey work, and amount involved in each category of cases, year-wise and company-wise is

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