Surveyor Management Policy int 2022 old

Application for Empanelment of New Surveyors as per Surveyor Management Policy*

1.Name of the Applicant

First Name *

Middle Name

Last Name

Attach Self attested Identity Proof *

(Allowed file type: Pdf, Files must be less than 2 MB)

2.Individual / Corporate *

INDIVIDUAL

CORPORATE

3.Address Of the Applicant(Registered Address of the Corporate Firm) *

4.Pincode *

5.City *

6.State *

Attach self- attested address proof *

(Allowed file type: Pdf, Files must be less than 2 MB)

7.Email Address *

Contact Number(Tel.) *

(Information on Item Nos. 8 to 13 should be provided for all the Directors/ Partners of the Corporate )
(Please attach separate sheet for subsequent Directors/Partners of the Corporate)

8.Qualifications (Attach Self attested Qualification Proof)

Academic

Professional

Insurance

Qualification Certificates *

(Allowed file type: Pdf, Files must be less than 2 MB)

9.Date of Birth/Age *

Month

Day

Year

DOB proof *

(Allowed file type: Pdf, Files must be less than 2 MB)

10.Membership with IISLA (Attach Self attested copy of Membership)

Membership no *

Level(F/A/L) *

YYYY *

11.IISLA Membership *

(Allowed file type: Pdf, Files must be less than 2 MB)

IRDAI Licence No *

Confirm IRDAI Licence No *

YYYY *

12.Licence valid upto *

Month

Day

Year

Upload IRDAI License copy(Attach Self attested Copy of License) *

(Allowed file type: Pdf, Files must be less than 2 MB)

Level of Membership *

13.State allocation of departments and Level of Membership

Department

13.A New applicants

13.B Applying for additional LoB*

Fire *

Marine Cargo *

Marine Hull *

Engg *

Motor *

Misc *

Crop Insurance *

LOP *

Others*

Any other relevant document

Yes

Any other relevant document upload *

(Allowed file type: Pdf, Files must be less than 2 MB)

Already empanelled Surveyors applying for additional LoB for which license obtained subsequently OR not empanelled during last exercises for any particular LoB *

14.Preferred area(s) of Operations (CITY/DISTRIC T/STATE): *

15.Experience(Attach Self attested copy)

As independent surveyor

Month

Experience (Under Senior Surveyor)

Month

Experience Certificate(Attach Self attested copy) *

(Allowed file type: Pdf, Files must be less than 2 MB)

16.Are you already empanelled with any other General Insurance Company? *

YES

Proof of empanelment with any other General Insurance Company *

(Allowed file type: Pdf, Files must be less than 2 MB)

LoB/s

PSGICs

Private GICs

17.Has your application for empanelment been rejected by any General Insurance Company/ have you been de-empanelled by any General Insurance Company/ have you been penalized by IRDAI? *

YES

18.If so, details thereof. (Last Three Financial Years)

(Allowed file type: Pdf, Files must be less than 2 MB)

19.Will working as a surveyor be your sole occupation? *

YES

Upload Signature *

(Allowed file type:gif,png,jpg Files must be less than 2 MB)

Place *

Date *

Month

Day

Year

20.Declaration: *

I confirm that the documents submitted by me/authorized signatory of the firm are in order and I agreed the interview either in person or through virtual mode at the place identified by the interviewing authority. I solemnly declare and confirm that the particulars given above are true to the best of my knowledge and belief.

status

Please note that mere eligibility, filing application and attending interview does not confer any right on the part of the applicant to be empanelled

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