TATA AIA

Application Type: New Agency Type: Business Associate Application No: A8151347

Channel: Agency IRDAI Unique Ref.no.(URN):

D.P.B.A : No
Office name: TATA AIA Delhi -
Agent code: 005683330 Office code: ND28 DSBA1 : No
NSP
DSBA2 : No

Signature of candidate:

FORM-1A
APPLICATION FOR APPOINTMENT TO ACT AS AN INSURANCE AGENT

(With a Life Insurer OR General Insurer OR Helath Insurer)

To:TATA AIA Life Insurance Company Ltd.
(Name of the Insurer),
14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel , Mumbai 400013.

Dear sir,
I request that Appointment to act as an insurance agent of your organisation may 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: ..NISHANT SINGH

(2)Title: ..MR

(3)Father's/ Husband's Name: ..Raj kumar

(4)Full Address:

House No: ..S MN 103 BLOCK NO 37 SUKHNARSI MURADNAGAR NPP GHAZIABAD Muradnagar PO Murad Nagar DIST Ghaziabad Uttar Pradesh
201206

Street:

undefined

undefined

Town: GHAZIABAD

District: Ghaziabad

State: UTTAR PRADESH

Pin Code: 201206

Mobile No: 6398508061

Tel./ STD Code:

(5)Date of Birth: Day-Month-Year: 28-03-1998 Attached Age Proof: No

(6)Educational Qualifications: 12th Pass [HSC]

12th Pass [HSC]

(7)PAN CARD Number: ISOPS6010J

(Attached Attested copy of the PAN CARD): No

(8)Give particulars of pass in pre-recruitment test conducted by the Insurance Institute of India or examination body:

Name of Examination Body:

Candidate's Name: NISHANT SINGH

Candidate's Number:

Centre of Examination:

Name of the Exam passed:

Date of Passing:

(9)Furnish the details of any insurance agency in force or ever hold by the applicant

Name of the Insurer: Agency Code Number: Date of Appointment as agent: Date of cessation of Agency: Reason for cessation of agency:

*Please attach Agency cessation letter issued by the insurer

10: Details of other insurance related activities undertaken, if any.

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.

Date: Place:

Yours faithfully:
Signature of applicant

CANDIDATE DETAILS

1. Maiden Name(Applicable for female candidates):

2. Marital status:

3. PAN: ISOPS6010J

4. Gender: Male

5. 1)Religion:

6. 1)Proposed Area of Operation:

7. a.Photo Identify proof: Yes

b.Identity Proof No:

8. Email Id: nishant508061@gmail.com

9. a)Basic Qualification: 12th Pass [HSC]

Year of Passing:

b)Roll Number:
Board Name:

10. Highest Qualification: 12th Pass [HSC]

11. Primary Occupation: Others

12. Nationality: Indian

13. a)Nominee Name: Prabha

b)Nominee Relationship: mother

c)Date of Birth of Nominee: 15-05-1971

d)Name of Appointee (In case Nominee is Minor):

e)Date of Birth of Appointee:

14.Have you ever been associated with Tata AIA Life Insurance Co. Ltd./any other insurer in any capacity?
No

If yes please specify:

15. Are you a relative*** of any employee of Tata AIA Life Insurance Co. Ltd.?
No

If yes, furnish name : and relationship :

Relatives is defined as "spouse, dependent children or dependent step children, whether residing with the employee or not"

16. Please confirm, that neither you nor any of your family member including distant relative has a agent/leader code under any other leader tree.
No
If no, furnish agent code: Or PAN number:

17. Are you associate with any other insurance intermediatory?

No

If yes, furnish code: and Intermediatory Name: and Current status:

18. Are you eligible for tax exemption under section 10(26) pr 10(26AAA) of the Income Tax Act, 1961?
No

19. Are you a Politically exposed person? ** (If yes please provide details*) No

"A "Politically Exposed person" is a person who performs important functions for the state. This would include individuals who have or have had positions of
public trust such as government officials,senior executives of govt corprations,politicians,important political party officials, member of legislative assembly, etc.,
and their families and close associates.
** politically exposed person who are or have been entrusted with prominent public functions, domestically/ in an international organisation/ in a foreign
country. This would include individuals who have or have had positions of Heads of State or of government, senior politicians, senior government, judicial or
military officials, senior executives of state owned corporations, important political party officials". "Close relations of PEP: Family members are individuals
who are related to a PEP either directly (consanguinity) or through marriage or similar (civil) forms of partnership, Close associates are individuals closely
connected to a PER either socially or professionally"

20. Please state whether you are registered with any Authority under any State or Central Act, as applicable to you?

No

Training &Examination(New)

Trainig Mode: offline

Location (City): TATA AIA LIFE INSURANCE COMPANY LTD -IRDA/ONA/ATI/MHA/MUMBAI/100

Institute: TATA AIA LIFE INSURANCE COMPANY LTD

Examination Mode: Online

Body: NSEIT

Location: NSEIT - Noida-Delhi NCR

Language: HINDI

Exam Date:

DECLARATION(for referring Agent/Applicant)

(1)From Agent/Application

I hereby declare that has been referred by me and needs to be assigned to the office code. The above candidate would be re-assigned to my PBA firm once the
same is coded.

Agent Name/Candidate Name:

Agent Code/Application No:

Signature

DECLARATION(for Agency verticals only)

(1)From ABAM/BAM/BM

I hereby declare that MR has been referred by me and needs to be assigned to Tata AIA Life Insurance Co Ltd. Office in my team.

Name of ABAM/BAM/BM/ADOA:
 Employee code:

Signature

DECLARATION(for Business Associate)

(ii)From Business Associate

We hereby declare that NISHANT SINGH has been recruited by our BA firm. Please assign him/her to our BA firm.

BA Name: SUKRIT JAIN

BA Code: 005683330

Stamp&Signature

DECLARATION

I NISHANT SINGH S/o Raj kumar

R/O
Aged about 27 years, Indian Inhabitant, do hereby declare as under:-
1) That, I have applied to be considered to become a life insurance agent of TATA AIA Life Insurance Co Ltd.Pursuant to which I have submitted following
document(s)/certificate(s) as a proof of my eligibility;

1. Age Proof
2. Education Proof
3. Aadhar Proof
2)That I have requisite educational qualification as prescribed by the Insurance Regulatory Development Authority of India (IRDAI) and the company for taking up life
insurance agency and I have submitted the proof of such qualification.

3)That the qualification proof/documents submitted by me are valid and true copies Of the original certificate issued by the appropriate authority(s).

4)I understand that Tata AA Life Insurance co Ltd. would be considering my application for insurance agency as well as making any subsequent contract of agency
based on the certificates I have provided and this declaration.

5)I understand that my agency code would be terminated if I fail to collect my letter of appointment within 90 days from the date of appointment.

I hereby certify that all the information given in this application form is true and correct and that the same has been personally entered and filled by me. I understand
that one of the important considerations for Tata AIA Life Insurance Co Ltd. for considering my application and taking a decision on engaging me as a life insurance
agent will be the information provided by me in this application form and the accuracy and correctness thereof. In the event it is discovered that any information
provided by me is not genuine or that it is fabricated or that any information was suppressed or presented in a false way; Tata AIA Life Insurance Co Ltd. may terminate
my agency without notice and Tata AIA Life Insurance Co Ltd. may take such legal action (including criminal action) against me and also recover from me monetary
compensation for all losses and damages suffered by Tata AIA Life Insurance Co Ltd. and all of the above shall be at my cost and consequence and responsibility. I
hereby solemnly declare and undertake that I have not been convicted of any criminal, civil or other offence under the applicable laws of India or any other jurisdiction.
I further declare and confirm that in case of any misrepresentation made by me or failure to furnish true information, the company shall be at liberty to proceed against
me and I shall assist the concerned authorities/Company in concluding the proceedings.

I understand that I need to furnish my Permanent Account Number (PAN) under sec. 206 AA of the Income Tax Act (IT) 1961 to the entity responsible for deducting
income tax from source of income, failing which tax shall be deducted at higher rates as applicable. I hereby state that I shall furnish my valid PAN card details at the
earliest to the Tata AIA Life Insurance Co Ltd. branch and agree that in absence of the same my licensing as an Insurance agent would be on hold.

(Signature of Applicant/Agent)

Candidate Profile Form

1.Age: >=20 &<=65 Yrs:

..27

2.Network: > 2 years (Same city stay):

..

3.Self owned vehicle (Mobility and social status):

..

4.Prior insurance selling experience:

 ..

Total count of Yes:

..1

Laptop/Other digital device

Smartphone:
Tab :
iPad :
Laptop/Other digital device :

Smart Phone Brand:

Smart Phone Model No:

Tablet Brand:

Tablet Model No:

iPad Brand:

iPad Model No:

The above details are authenticated and verified by :

Signature Leader:

Signature Branch Head:

Note: 3 out of 5 criteria to be fullfilled

Tata AIA Life Insurance Company Ltd. (IRDA of India Regn. No. 110 CINI: IJ66010MH2000PLC128403).
Registered &Corporate Office Address: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013.
Visit us at www.tataaia.com *For internal circulation only.

BEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS/FRAUDULENT OFFERS

IRDA of India clarifies to public that
IRDA of India or its officials do not involve in activities like sale of any kind of insurance or financial products nor invest premiums.
IRDA of India does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details of phone call, number.

New Advisor Screening Form

Part-A

Family Background and Income

Family Income >= 400000

Remarks:

Anyone in family engaged with BFSI sector -Code with LI/GI/MF

Remarks:

Lifestyle and Social Status

Owns a House

Remarks:
Family Lifestyle
Owns a Vehicle

Remarks:

Association with any social Club/Commitee/equivalent

Family Network
Remarks:
Relevant Experience

Insurance/Other Investment products (2 Points)

Which Industry
Remarks:

Housewife,'Taxation/Pharma/Education/Any profession which builts a clientile:

Other Profession/status
Remarks:

Area/Function of experience-Sales:

Remarks:

Readiness to be groomed

Readiness to invest stipulated time-Min 4 hrs a Day and 25 Hrs a week

Remarks:

Interpersonal Skills-Can communicate well:

Remarks:

PART- B

Business Acumen

What is the life insurance industry all about?

Notes:

What do you look for in a new business opportunity ?

Notes:
Communication Skills

Have you ever had to convince someone that you were right?

Notes:

How would you go about making new friends with strangers?

Notes:

Motivation Resilience

What motivates you?

Notes

Tell me about your biggest success in life?

Notes:

Can you recall a difficult situation in your life and how did you deal with?

Notes:

Commitment

How does your family feel about you working in this industry?

Notes:

How much time can you dedicate to running this business in a week?

Notes:

Willingness to be trained

In terms of business knowledge, which areas would you be keen to improve?

Notes:

What was the most recent training/course you attended, tell me about it.
Notes:

Attitude

What makes a person successful?

Notes:

Which parts of your character do your friends like most about you?

Notes:

Natural Market

How many contacts can you list that you've known through your spouse, children,religious activities, social groups or hobbies?

Notes:

This part of the selection interview form will be used after the interview has ended. It is meant to assist you to weigh the potential of your candidate for
further screening.

Do this immediately after each candidate

Score them on the scale of: 3.Good, 2- Average, 1- Poor

Tabulate the candidate's overall score.

Plot the number of the overall score on the 'selection scale' below

Business Acumen

Score:

Communication Skills

Score:

Motivation & Resilience

Score:

Time Commitment

Score:

Willingness to be trained

Score:

Attitude

Score:

Natural Market

Score:

Score Guide on Total Score (PART A+B) Score Guide on Total Score (PART A+B)

< 20 -Reject PART A No of YES-

> = 20 < 24 -Recruit with Caution PART B Total of all Sections

>= 24 -Actively Recruit Total

SALES MANAGER'S REPORT OF THE APPLICANT

I certify that I have personally interviewed the applicant and conducted the applicant profiling and confirm that the details mentioned in the Agent Application form
is correct. The answers given in the application are true and correct to the best of my knowledge and the applicant is suitable to become an advisor with Tata AIA
Life Insurance Company Ltd.

Name of the Sales Manager Signature

Employee Code

Agent Pre NAAF Declaration

Date

Name

I hereby, aknowledge that i have completely understood the career roadmap as an insurance agent, and would like to pursue this career. I also acknowledge and
agree that i would be attending the 5 day training program as a start of my training roadmap and would continue to invest in future for training and technology
which would help in making me successful in this career.

Candidate Signature Branch Head Signature

CHECKLIST OF DOCUMENTS TO BE ATTACHED WITH AGENT APPLICATION FORM

Sr. No. PARTICULARS Sr. No. PARTICULARS:

A AGENT APPLICATION FORM (AAF) 11 In case of transfer case check for cessation certificate of
previous company
1 Name of the Sales Manager, employee code & office code should be clearly mentioned
*SM BOE
*SM BOE
12 In case of Composite License holder check for Form 1B
2 2 latest colour photograph of the Candidate attested by authorized signatory along with stamp of General
insurance Company
*SM BOE
*SM BOE
3 Name of the Candidate on the pre-Agent Application Form matches with the
documents provided. 13 NEFT / Bank A/c details should be updated properly

*SM BOE *SM BOE

4 Name of the Father/Husband matches with the documents provided. B DOCUMENTS PROVIDED

*SM BOE 1 Age Proof (Birth Certificate / Passport / PAN Card Copy)

5 Date Of Birth (DOB) on the Pre-Agent Application Form should match With DOB
proof provided 2 Education Proof (Mark sheet / Relevant -Board,University
Certificate)
*SM BOE
 6 Address of the Candidate mentioned on the pre-Agent Application Form should match 3 Residence proof as per KYA guidelines
with Residential Proof Provided.

*SM BOE 4 Photo Identification proof as per AML guidelines

7 PIN Code Provided on pre-Agent Application Form should match with residential
Proof Provided. 5 Self Declaration letter (In case of Married Woman)

*SM BOE
6 Name correction letter (In case of name mismatch)
8 Check for Photocopy Of PAN CARD / PAN Application form

*SM BOE 7 Marriage certificate / Gazette proof (In case of name change)

9 Educational Qualification on Pre-Agent Application Form should match with the

documents provided for the same 8 Permanent Address Proof (If Applicable)
*SM BOE
9 Caste Certificate (If Applicable)
10 Check for Sales Manager, Agent Sign, Stamp & Code in the Application Form

*SM BOE 10 Photocopy Of PAN Card 'PAN Application Form

*SM - Sales Manager

Date: Branch Executive

Verified by (Name of Branch Executive)

Employee Code Signature

IFSC Code certification by Account Holder's Bank(Mandatory)

Account Holder Name

NISHANT SINGH

Name of the Bank

FEDERAL BANK

Branch Address
EPIFI FEDERAL NEO BANKING

Account number
55550110957907

Type

Saving/Current
Savings

Agent code/Applicationno:

Account Holder Signature:

Certification By Account Holder's Bank:

(Only if cancelled cheque is not provided)

Certify that the above account is currently operational and the particulars furnished are correct as per our records. We would also like to confirm that our
branch is NEFT enabled and our IFSC code is as mentoned below.

IFSC Code
FDRL0005555

Date

Authorized signatory

Bank Stamp