FORM I-B

APPLICATION OF AN EXISTING INSURANCE AGENT FOR

APPOINTMENT TO ACT AS COMPOSITE INSURANCE AGENT WITH
ANOTHER INSURER(LIFE OR GENERAL OR HEALTH INSURANCE OR MONO-LINE INSURANCE)

NAME OF INSURANCE AGENT : KODATI DHANALAKSHMI

DETAILS OF THE INSURANCE AGENCY HELD(Past & Present)

Name of the Insurer Agency Code Number Date of Appointment as Date of cessation of Reason for cessation of
Agent Agency Agency
Life Insurance 06006686 01-04-2015
Corporation of India

Note If Agency is currently in-force with an insurer mention INFORCE in the column Date of cessation of
Agency

COMPOSITE INSURANCE AGENCY APPOINTMENT now being sought with

Life Insurer Life Insurance Corporation of India

General Insurer
Health Insurer

Other Mono-Line Insurer

** Mention name of the Insurer in the Box above

Note:

(i) No person shall act as an insurance agent for more than one life insurer, one general insurer, one health insurer
and one of each of other mono-line insurers

(ii) Any person who acts as an insurance agent in contravention of the provisions of this Act, shall be liable to a
penalty which may extend to ten thousand rupees

(iii) Attach Separate Application Form for each of the Insurance Organisation with whom you seek to obtain
Appointment and submit all the Application Forms to your current insurer only.

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 APPLICATION FOR APPOINTMENT TO ACT AS AN INSURANCE AGENT

(With a Life Insurer OR General Insurer OR Health Insurer) for the FIRST TIME.

To

Star Health and Allied insurance Co. Ltd

Madam,
I request that Appointment to act as an insurance agent of your insurance Organisationmay be granted to me.

I hereby declare that particulars given below are true and that the APPOINTMENT for which I apply will be used
only by myself for soliciting or procuring insurance business for your Insurance Organisation

(1) Name : KODATI DHANALAKSHMI

(2) Title : Ms.

(3) Father Name : Pamuswami Venkuru

(4) Full Address:

Address Line1 9-125,near Water Plant

Address Line2 Rama Nagar Katta, Tadigadapa
Address Line3 .
City Kanuru (CT)
District Krishna
State Andhra Pradesh
PIN Code 521137
Mobile No 8688199416

(5) Date of Birth: Day-Month-Year 01-06-1978 Attach Age proof

(6) Educational Qualifications. (Tick the right Box)

Class X Class XII Graduate Post Graduate Other

(7) PAN CARD Number: AXYPL5934E (attach Attested copy of the PAN CARD)
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 (8) Give particulars of pass in pre-recruitment test conducted by the Insurance Institute of India or any examination
body:

Name of Examination Body:

Candidate's Name:
Candidate's Number:
Center of Examination:
Name of the Exam passed:
Date of Passing (Day-Month-Year)
Note Attach certificate issued by the examining body

(9) I declare that----

a) I have not been found to be of unsound mind by a court of competent jurisdiction;

b) I have not been found guilty of criminal misappropriation or criminal breach of trust or cheating or forgery or an
abetment of or attempt to commit any such offence by a court of competent jurisdiction;

c) I have not been found guilty of or to have knowingly participated in or connived at any fraud, dishonestly or mis-
representation against an insurer or an insured.

d) I have not violated the Code of Conduct specified under Clause 7 of the IRDAI (Appointment of Insurance agents)
Guidelines, 2015.

Place: Yours Faithfully,

Date: 28-05-2023 Signature of applicant

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 Notes and Instructions

a) The application should be filled in, as far as possible, in Hindi language or English language.

b) Any correction or alteration made in any answer to the questions in the application should be initialled by the
applicant.

c) An applicant must be at least 18 years of age on the date of the application. If required the applicant shall furnish
proof of age.

d) An applicant shall furnish the proof of pass in the Insurance examination conducted by the Insurance Institute of
India, Mumbai or an examination body approved by the Insurance Regulatory and Development Authority of India,
along with the application.

e) The following documents should be attached with the application (a) Age Proof (b) Educational Qualifications (c)
Proof of pass in the agency examination as mentioned above (d) Copy of PAN Card (e) Address proof to the
satisfaction of the insurer (f) Cessation Certificate if any, that is held by the Agent

Note to the Insurer:

(1) The applicant should be provided with an acknowledgment for the receipt of the Agency Application form

(2) The details in the application form should be verified with the data available with the insurer and the application
form with due authentication should be forwarded to the insurer with whom the applicant is seeking Agency within 15
days of the receipt of the application form from the applicant. A copy of the forwarding letter should be sent to the
applicant for his records.

(3) The designated official of the Insurer should ensure that under no circumstances, there is a delay in forwarding the
application form to the concerned insurer.

(4) The applicant shall ascertain from the Insurer to whom he has submitted the Agency Application form on the
status of the Agency application submitted by him.

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