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FIT and Proper Declaration

Gaurav Kumar is applying to be a surveyor and loss assessor. He provides personal and professional details in the application form. This includes his education background of B.Com and AIII, over 8 years of relevant work experience in insurance claims and fraud control, and that he has not had any regulatory, legal or disciplinary issues in the past. He signs to confirm the truth and completeness of the information provided.

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Gaurav Kumar
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1K views

FIT and Proper Declaration

Gaurav Kumar is applying to be a surveyor and loss assessor. He provides personal and professional details in the application form. This includes his education background of B.Com and AIII, over 8 years of relevant work experience in insurance claims and fraud control, and that he has not had any regulatory, legal or disciplinary issues in the past. He signs to confirm the truth and completeness of the information provided.

Uploaded by

Gaurav Kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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SCHEDULE-1

Annexure-2

IRDA (Insurance Surveyors and Loss Assessors) Regulation, 2015

FIT AND PROPER CRITERIA (Regulation 4)

Name if the Surveyor (Corporate Surveyor)


I Personal Details
. a. Full Name Gaurav Kumar
b. Position in surveyor entity
c. Date of Birth 10th February 1992
d. Education Qualification B.Com, AIII
e. Relevant Background and Experience Working experience of 3 Years in Health Insurance
Company under Fraud Control Unit and 5 Years in a leading
Cement Manufacturing company under Insurance and Claim
Department.

f. Permanent Address Vill.:- Jagdishpur Rami, P.O.:- Chakhajee, Dist.:-


Samastipur, State:- Bihar, Pin Code:- 848115.

g. Present Address Vill.:- Jagdishpur Rami, P.O.:- Chakhajee, Dist.:-


Samastipur, State:- Bihar, Pin Code:- 848115.
h. Email address / telephone Number [email protected]
i. PAN under Income Tax Act Name and address of Income BXHPK2580E
Tax Circle Samastipur, Bihar
j. Address Proof
Experience of 5 Years in Marine Cargo, Fire, Engineering,
k. Relevant Knowledge and experience in Insurance Motor, and Miscellaneous claim as a Insured Part in a
Leading Cement Manufacturing Company.
l. Any other information relevant to position NIL
I If answer is YES to any of the question; please give full details.
I
. a. Have you ever registered or obtained licence from any of No
the regulatory authorities under any law as SEBI, RBI,
IRDA, PFRDA etc.
b. Have you carried on business under any name other than No
the name stated in this application
c. Have you ever been refused or restricted by any regulatory
authority to carry on any business, trade or profession for No
which a specific licence registration or other authorization
is required by law
d. Have you been ever censured or disciplined or suspended No
or refused permission or licence or registration by any
regulatory authority to carry on any business activity
e. Have you been subject to any investigations of disciplinary No
proceeding or have been issued warning or reprimand by
any regulatory authority
f. Have you been convicted of any offence or subject to any No
pending proceeding under any law
g. Have you been banned from entry at any No
profession/occupation at any time.
h. Details of prosecution, if any, pending or commenced or Not Applicable
resulting in conviction in the past for violation of
economic laws and regulations
i. Details of criminal prosecution, if any, pending or Not Applicable
commenced or resulting in conviction in the past against
you

1
SCHEDULE-1
Annexure-2

IRDA (Insurance Surveyors and Loss Assessors) Regulation, 2015

FIT AND PROPER CRITERIA (Regulation 4)

j. Do you attract any of the disqualification envisaged under No


Section 164 of the companies’ Act 2013?
k. Have you been subject to an investigation at the instance No
of Government department or agency?
l. Have you at any time been found guilty of violation of
rules/regulations/legislative requirements by customs / No
excise / income tax / foreign exchange / other revenue
authorities, if so give particulars
m. Have you at any time come to the adverse notice of a
regulator such as SEBI, IRDA, DCA.

(Though it shall not be necessary for a candidate to No


mention in the column about orders and findings made by
regulators which have been later on reversed / set aside in
toto, it would be necessary to make a mention of the same,
in case the reversal / setting aside is on technical reasons
like limitation or lack of jurisdiction, etc, and not on merit.
If the order of the regulator is temporarily stayed and
appellate / court proceedings are pending, the same also
should be mentioned).
n. Has any of your group company/associate company/related No
party been carrying any licence issued by the IRDA
I Undertaking
I
I I Confirm that the above information is, to the best of my knowledge and belief, true and complete. I undertake to keep the
. Authority informed, as soon as possible, of all events, which take place subsequent to issuance of my licence to act as Surveyor
and Loss Assessor, which are relevant to the information provided above.

Place :- Samastipur, Bihar. Signature:-

Date:- Name: Gaurav Kumar

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