1. Name of the applicant *
2. Individual / Corporate *
3.
b. Pin code *
c. Email *
d. Mobile/Telephone Number (with STD code) *
4. Qualifications *- Academic *
Qualification Certificates *
- Professional *
Qualification Certificates *
- Insurance *
Qualification Certificates *
Upload Insurance Qualification Details *
(Information on Item Nos. 4 to 9 should be provided for all the Directors/Partners of the Corporate)(Please attach separate sheet for subsequent Directors/Partners of the Corporate) *5. Date of Birth/ Age *
6. Year of membership with IISLA *
IISLA Membership *
7. IRDAI Licence No */
/-
Upload IRDAI License copy *
8. Licence valid upto *
9. State allocation of departments and Level of Membership *Level of Membership *Fire
Marine Cargo
Marine Hull
Engg
Motor
Misc
Crop Insurance
LOP
Others
Any other relevant document
10. Preferred area(s) of Operations(CITY/DISTRICT/STATE) *
11. Experience (as independent surveyor/ under senior surveyor) *
Experience Certificate *
12. Are you already empanelled with any other General Insurance Company? If so, the details thereof *
Proof of empanelment with any other General Insurance Company
13. 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? *
14. If so, details thereof (Last Three Financial Years). *
15. Will working as a surveyor be your sole occupation? *
Upload Signature
Upload photo
Place *
Date *
I confirm that the documents submitted by me/authorized signatory of the firm are in order and I agreed to attend 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.
(Please note that mere eligibility, filing application and attending interview does not confer any right on the part of the applicant to be empanelled.)