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Agent Sponsorship Form

1) The document is a sponsorship form for insurance agent licensing. 2) It collects personal information about the applicant such as name, address, date of birth, education level, and professional details. 3) The form also requests information about the applicant's training, examination, and licensing details to become an insurance agent. Key details include examination body, mode, center, and language.

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4K views4 pages

Agent Sponsorship Form

1) The document is a sponsorship form for insurance agent licensing. 2) It collects personal information about the applicant such as name, address, date of birth, education level, and professional details. 3) The form also requests information about the applicant's training, examination, and licensing details to become an insurance agent. Key details include examination body, mode, center, and language.

Uploaded by

Alok
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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SPONSORSHIP FORM

For DTC Purpose: Branch Name : S.L.NO.


URN NO. D.O Code Number :
D.O Mobile Number :
IR NO MR No. & Dt. (Rs.150/-) :
SL.NO MR/Cheque No.(Rs. 350/-) :

Sponsoring Company Name : LIFE INSURANCE CORPORATION OF INDIA


In Charge/Authorised Person Name :
Licence Type : ( ) INDIVIDUAL ( ) CORPORATE
Insurance Category : ( ) LIFE ( ) GENERAL
Is Specified Person? : ( ) YES ( ) NO If YES, Licence No:

Applilcant Details
Application Date (DD/MM/YYYY) :
Personal Information:
Applicant Name
Father/Husband Name
Category ( ) General ( ) SC ( ) ST ( ) OBC
Area ( ) Urban ( ) Rural
PAN ( ) :
Driving Licence No.( ) :
Passport No. ( ) :
Voter Identity Card* ( ) :
Photo ID Card of Govt. ( ) :
Basic Qualification Details : Class X/ Class XII
Board Name:
Roll Number:
Year of Passing:
Educational Qualification Any of below:
( ) Class X ( ) Associate/ Fellow of Insurance Institute of India
( ) Class XII ( ) Associate/Fellow of Institute of Cost and Works Accounts
( ) Graduate ( ) Associate/Fellow of Institute of Company Secretaries of In
( ) Post Graduate ( ) Associte/ Fellow of Acturial Society of India
( ) Master of Business Administration
( ) Others:

Date of Birth (DD/MM/YYYY):


Sex:
Primary Profession:
Nationality: INDIAN
Current Address: Permanent Address:
House Number: House Number
Street/ Road: Street/ Road
Town/ City: Town/ City
State: State
District: District
PIN Code: PIN Code

IIA IIA
Res. Number Res. Number:
Mobile No: Mobile No:
email id: email id:

Other Information:
Training at A.T.C. / D.T.C :
Examination Mode ( ) ONLINE ( ) Offline
Examination Body : INSURANCE INSTITUTE OF INDIA
Examination Center :
Examination Language : ( )ENGLISH ( )HINDI ( )

(Signature of Applicant)

Authorised S
CM/ SBM/ BM
(Signature of SBA)

Date:

IIA IIA
SORSHIP FORM

If YES, Licence No:

Applicant Photo

Applicant Signature

Associate/Fellow of Institute of Cost and Works Accounts of India


Associate/Fellow of Institute of Company Secretaries of India

IIA IIA
Authorised Signature with Stamp
CM/ SBM/ BM/ ABM/ PRINCIPAL

IIA IIA

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