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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY - page 24 / 28

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

NOT TRANSFERABLE

LICENCE NO. …………………….

RENEWAL OF LICENCE TO ACT AS A SURVEYOR/ LOSS ASSESSOR

UNDER THE INSURANCE ACT, 1938

Passport size Photo

Mr./ Mrs./ Miss……………………

Address……….……………………

………………………………………

* working as sole proprietor of ………………………………………………………… ……………………..having paid the specified fee and having made the necessary declaration, his/ her Licence No. …………… dated ………………… to act as a surveyor/ loss assessor is hereby renewed upto ……………….. day of ……………….. 20 ……….

Name ……………………………………… are allocated the following departments and category:

Depts

Fire

Mrn Cargo

Mrn Hull

Engg.

Motor

Misc.

LOP

Category

New Delhi, dated the ……….. 20…..

Signature of the Licence holder ………….

Chairperson/ Designated Official

Insurance Regulatory and Development Authority

* (Strike out if not required)

(See Notes on the reverse)

Notes

1.

If it is desired to renew this licence a further for a period, the procedure laid down in Rule 56 of the Insurance Rules, shall be followed, and an application for renewal should reach the Insurance Regulatory and Development Authority atleast thirty days before the licence expires.

2.

This licence authorises the licence holder to act as a surveyor/ loss assessor for any registered insurer and therefore, no identifying mark or note of any description by which the identity of an insurer might be established should be placed on the licence.

3.

No correction in this licence will be valid unless initialled by the Chairperson, Insurance Regulatory and Development Authority or a person authorized by him in this behalf.  

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