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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY - page 28 / 28

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FORMAT FOR ANNUAL SUBMISSION OF RETURN TO THE AUTHORITY (Regulation No. 13(b)(ii))

1.

Name:________________________

2.

Current Licence No. & Date of Expiry :________________________

3.

Qualifications acquired in the past one year:

Academic/Professional:________________________

Insurance:_______________________

Training Attended (Nature

and duration) :________________________

4.

No. of surveys done in last financial year and the name of insurers:

20__-20__

Insurers

Fire

Mrn. Cargo

Mrn. Hull

Engg.

Motor

Misc.

LOP

Total

A

B

C

D

5.

Quantum of losses assessed in last financial year:

20__-20__

Fire

No.

Mrn. Cargo

No.

Mrn. Hull

No.

Engg.

No.

Motor

No.

Misc.

No.

LOP

No.

>10 Lacs

>1 lac

>10 lacs

>2.5 lacs

>50,000

>1 lac

>10 Lacs

1-10 Lacs

25,000-1 lac

2.5-10 lacs

50,000-2.5 lacs

10,000 –50,000

25,000-1 lac

1-10 Lacs

0-1 Lac

0-25,000

0-2.5 lacs

0-50,000

0-10,000

0-25,000

0-1 Lac

Total

6.

a) Income derived from survey work during the year. Rs.______

b) Profit after deducting for management expenses. Rs. ______

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

Signature:  ___________________________

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