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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY - page 22 / 28

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enclosed.

(vii)

In addition to surveyor’s work, I am also engaged on other occupations, the details of which are given below:

Or

I am not engaged in any other occupation.

(viii)

I have not violated the code of conduct of the Authority

(ix)

I have not contravened any of the provisions of the IRDA Act, 1999, Insurance Act, 1938, Rules and Regulations made thereunder including any order or directions issued by the Authority or any of its designated persons;

(x)

I have not made a statement which is false in material particulars with regard to my eligibility for the licence or renewal thereof or in any of the activities transacted by me or the matters connected therewith as a Surveyor and Loss Assessor;

(xi)

I have neither attracted the disqualification provisions referred to in the Insurance Act, 1938 nor violated the code of conduct; and

(xii)

I have performed the duties & responsibilities as a professional.

(xiii)

I enclose 4 passport size photographs.

3.

Whether the applicant has been in practice as a Surveyor/Loss Assessor on the 31st May, 1970 (say Yes or No) if answer is in affirmative and the applicant is not eligible to come under any or sub-items (a) to (e) in items below.  The declaration in the annexure to this form should be filled in a duly sworn before a Magistrate, Notary Public or Justice of Peace.

4.

I also declare that the facts stated herein are true.

5.

In case licence is submitted after expiry, the licence fee will be Rs.250/- instead of Rs.200/-.  (Along with photocopy of qualification duly attested by notary See Serial No. 4 of the application notes).

Yours faithfully,

Signature of the Applicant

Dated--------------------

Check List:

(1)

D.D. in favour of Insurance Regulatory and Development Authority, payable at New Delhi)

(2)

Copy of previous licence

(3)

Qualification copy

(4)

Affidavit

(5)

Work performance report

(6)

Self-addressed envelop size 4.5” x 10” with Rs.17/- postage stamps.

(7)

4 no.’s passport size photographs

Notes

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