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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY - page 5 / 28

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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY

FORM - IRDA – 1A – AF (Regulation 3(g))

To be filled by every person of the Company/ Firm

“Person” means a director of the company/ partner of a firm/ employee of a company/ firm who can carry out the work of Surveyor and Loss Assessor.

Passport size Photo

(3+1)

1.

Name:______________________

2.

Date Of Birth:______________________

3.

Current Licence No. &

Date of Expiry :______________________

4.

Nationality:______________________

5.

Qualification (of the person of Company/ Firm )

a)

Academic/professional            ---------------------------------------------

b)

Insurance ---------------------------------------------

c)

Training attended (Nature – duration)---------------------------------------------

6.

Communication

Phone Office

Phone Res.

Fax

Pager

Mobile

E-Mail

7.

Date of Birth of the person of the Company/ Firm in Christian Era: _________________________________

8.

Insurance Surveyor & Loss Assessor Examination Details of the person of the Company/ Firm.

Name of partners/ directors qualifying the exam

Dt. Of Exam

Roll No.

Centre

Institute conducting the Exam

Result

9.

Practical Training Details of the person of the Company/ Firm. (Please enclose the certificate of training obtained from the surveyor/ survey firm)

Name of Surveyor/ Survey Firm

Departments Allocated to the Surveyor/ Survey Firm

Category Awarded to the Surveyor/ Survey Firm

Period of training undergone (Please mention dates)

Name of person(s) under whom training undertaken

Areas covered

Result

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