Star Health and Allied Insurance Co.

Ltd Aff xsf attestet

No:15, 4h Floor, Sri Balaji Complex, Whites Lane,
Lalest aspart
STAR orsc: Ci
Heath
nsurance
Royapettah, Chennai 600 014. Phone : 044 4051 6672/6674/6676.
CIN:U66010TN 2005PLCO56649,1RDAI Regn.No:129.Email:businesscodes@starhealth.in
MIS FORM - AGENT APPOINTMENT
Stee ohotograph
ot the Appicast
The Heatth tnsurance Speciallst
Note: Please fill the form in CAPITAL LETTERS only A fields are COMPULSORY]
1

2
Applicant Name (As per PAN Card)
Title
RAKHI DE
Mr. Ms. Mrs. D Mx.
3 Father Name/ Spouse Name
4 Gender
SUKHENDU DEB
Male Female Transgender
5

6
Date of Birth (DD/MM/YYY)
Full Address
02 1977
Address 1
a
House/Flat No. wARO NO2 StreetARORTN DA PALY
Address 2
RABTNDRA SARANI
C Address 3
SILIGRI M. Corp
d) City / District
SILIGuRr 9 JALPAIG URT
e) State
WEST BEN GAL f) PIN Code
7346 734 D0G
Mobile No: +91- 3430715 h)
7 Rural/Urban Rural
E-mail ID:
pratuideQglCern
Urban
Xclass XII ClassD Graduate DI Post Graduate Other
Educational Qualifications
Professional Qualification [ If Any]:
9 PAN No:
BBDPD75EA
10 Aadhar No [Optional ] 3787- G8J2- 8257 11 Blood Group
Details of Insurance Agency Examination Passed Earlier
12
[For Composite Agent Only
Life General D
Requesting Sponsorship for IC- 38 Health Preferred
Preferred Preferred
13
Insurance Examination [For Direct Agent Only Exam Date: 27/03/2024 Exam Siliguri Exam English
Center:
Language:
14. Office Code: Office Name SILIGURI 2O Zone:
Fulfiller
15.

16.
Fulfiller Code:SH73248 Fulfiller Name :
PRABIR DEXDesignation;
Details of past association with Star Health and Allied Insurance Co. Ltd if any
SM
17. Details of relatives working/worked in Star Health and Allied Insurance Co.Ltd if any
18. Details of relatives working / worked in hospitals/TPA/other Insurance companies f any NO
19. Are you facing any criminal case/convicted by any court?
Note: Please attach self attested copies of the following documents which are COMPULSORY.
i
Form IA (For Direct Agent )or Form IB (For Composite Agent)- duly filled Copy of PAN Card
and signed by the applicant
Copy of Educational Certificates Copy of Address Proof
Copyof Educational Certificates iv Copy of Address PrOof
vi
Cancelled Cheque Leaf / Bank Pass
NEFT Form Book

Dedaration: Theabove information and attachments are true and correct to the best ot my knowledge. Iagree that in case the above information
is found to be false / incorrect, my Agency is liable to be terminated.
Place SLLGDRI Date: Signature of the Applicant
For Office Use Only{ For BM Incentive Purpose ]
Unit Head Code Unit Head Name Unit Head Designation
20 BAKSHI
SH 79o o DEBU

Signature of Branch Head