Star Health and Allied Insurance Co.

Ltd Paste self

No: 47/10, 3d Floor, SarangapaniStreet,Habibullah Road,
x.*i
**** h;ffiT.Nagar, Chennai 600 017. Phone : 044 - 2828 8800. attested Late5t
Passport size
CtNrU55010TN2m5PtC056649,tRDAr Regn.No:129.Emait: blgliesscodes@starhealth.in
photograph
MIS FORM - AGENT APPOINTMENT
!9!g! Please flllthe form ln CAPITAI LETTERS only [Allflelds are COMpUtSORyl

1 Applicant Name (As per PAN Card)

2 Title ISalutation ] Mr. E us.E urs. ! M*. E

3 Father / Spouse Name

4 Gender: Male ! Female ! Transgender !

5 oate of Birth (ddlmm/yyyy)
6 Full Address

a) Address l House/Flat No. Street

b) Address 2

c) Address 3

d) City / District
e) State

f) PIN Code

c) Mobile No I Mandatory l +91-

h) E-mail lD I Mandatory ]
7 Rural/Urban Rural ! Urban !
x class E xll Clars E Graduate I Post Graduate E Other I
8. Educational Qualifi cations
Professional Qualification lif anv] :

9 PAN No I Mandatory ]

10 Aadhar No I Mandatory l
Details of lnsurance Agency Examination Ifor Composite Agent ]
11
lc 33 (Life) E lC 34 {General) E lc 38 [ Life / General ] E
Prefer,ed Examlnatlon Date:
Requesting Sponsorship for lC-:18 Health lnsurance
72 Prefered Examinatlon Lantuatel
Examination I OlrGGt Atent Only I
Prefefi ed Examlnatlon Center:

13 office code I Mandatory] : Of{ice Name I Mandatory] :

74 Fulfiller Code I Mandatory] : Fulfiller Name I Mandatoryl :

Note: Please att.ch self atterted coples olthe followlnt do.uments whlch are COMPU6ORY.
I Form r A E(lc 38 Direct Only) Form rB E (lc 33/34lrC38 Composite) Copies of Educational Certificates tr
I Copy of PAN Card tr Copy of Proof of Address tr
iii Copy ofAadhar Card tr cancelled Cheque Leaf/ Bank Pass Book tr
NEFT Oetalls

Name of the Bank Bank Branch

Eank Account no IFSC Code

ggd!I!!!g!: The above stated information and the enclosed attachmentl are true an d correct to the best of my knowledge. I aSree that
in case the above information is found to be false / incorreqt, myASency enrolment is liable to be terminated.

Place 0ate: of the lcant

 rORM I-B
APPLICATION Or. AN EXISTING INST'RANCE AGTI{T FOR
APPOINTMEilT TO ACT ASI COIUPOSITE IITSURANCE AGEITT UrITH
AITOTHER INSI'RER (LITE OR GENRE,AL OR HEALTH INSURANCE OT
MOIYO-LrIIE IISI]RANCEI

NAME OF INSURANCE AGENT

DETAILS O,F THE INSI'RANCE AGENCY HELD &

Name of Agency code Date of Date of Reason for
the lnsurer Number Appointment cessation of ccssation of
as aEent Agency agency

Note If Agency is currently in-fofce with an insurer mention

'INFORCE" in the column Date of cessation oI Agency '
CoMPCTSITE ffSITRANCE AGENCY APPTOUSTMEIT now betng sought wlth

Life Insurer
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 onc of each of
other mono-line insurers
(ii) Any person who acts as an insurance agent in coRtravention of
thc provisions of this Act, shatl bc liable to I penalty which may
extend to ten thousand ruPees
(iiilAttach Separate Application Form for each of the Insurance
Organisation with whom you scek to obtain Appointment and
submit all the Application Forms to your currelt insurer oaly.

fy
Page l7 of2a
Ouidelines lor Appointmcnt of lnsutaoce Agcnts
 APPLICATIOI{ T.ORAPP'OINTMEIIT TO ACT AS AN IIVSURANCE AGEIT

lWtth a Llfe Iasurer OR General lrrsurer OR Health Ineurer! for the

T'IRTTT TIME.

TO

(Name of the Insurer),

Paste self
attested
passport
Size
Photograph
DEAR SIRS,

I request that Appointment to act as an insurance agent ofyour

insurance Organisationmay be gmnted to me.

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

(1)Name: I It 1t lt II II lt lt It II lt ll 1t lt lt I
(2)Title : State 1 if are Mr., 2 Mrs., 3 Miss: tl
(3) Father's/Husband's Name t It lt ll 11 1l lt lt ll ll lt lt lt ll lt I
(4) Fltl Address: '
House
No
Street
Town
District
State
Pin Code
Mobile
No

(5) Date of Birth: Day- Month-Year [ ]t l-t I t 1-t lt ll lt I Attach Age proof

(6) Educational Qualilications. ftick the right Box]

Class X Class XII Graduate Post Other
Graduate

(7) PAN CARD Number (attach Attested copy of the PAN

cARD)

Guidelinrs for Appointment of lnsurancc Agcnts

l_
Page l8 ol2,l
(8) Give particulars of pass in pre-recruitraent test conducted by the
Insurance Institute of lndia or any examination body:

Name of Examination
Body:
Candidate's Name:
Candidate's Number:
Centre of Examination
Name of the E*am
passed
Date of Passing (Day- Month-Ycar)
Note Attach certilicate issued by the examining
body

9. I declare that----

a) I have not been found to be of unsound mind by a court of corgpetent

jurisdiction;
b) I have not been found guilty of criminal misappropriation or criminal
breach of trust or cheating or forgery or an abetrocnt 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
ineurer or an insured.
d) I have not violated the Code of Conduct specified under Clause 7 oI the
IRDAI (Appointment of Insurance agents) Guidelines, 2015. ,
Place Yours faithtully,

Date: Signature of applicant

Cuidclincs for AppointmcDt oflnsuancc Agcnts

L
Pago t9 of24
 DIRECT BANKCREDTT [DBC] FORM
To
The Incentive cell Department
Star Health and Allied insurance Co. Ltd,
Corporate office - chennai

I request you to credit my Commission / Incentive to the Bank account as stated below
(Please fill the form in Block Letters only)
Beneficiary Code I Agent / Sales Manager / TSE{rade-l/ TSE-Grade-ll]
[Strike offwhichever is not applicable)
Beneficiary Name

Branch Name: Office Code

BENEFICIARY NAME IIIIIII II

(fu per the Bank Account)
IIIIIII II
I IIIIIII I
BANK NAME
I IIIIIII I
IIII
ffi
BANK BRANCH NAME

II
BANI( BRANCH ADDRESS

ffi
P I N C o D E

FULL BANK ACCOUNT NUMBER IIIIIIIIIIIIIIII

IFSC CODE OF BANK BRANCH

BENEFICIARY PAN NUMBER

BENEFICIARY E-MAIL ID
m r
BENEFICIARY MOBILE NUMBER

I hereby declare that the particulars given above are true and complete.
IIIII
Date Signature of the Beneficiary

Note -Please attach the scan copy ofCancelled cheque leaf/Bank passbook/Bank StatemenL

business code/employee ID............,..............,...............has been duly verified and found to be correct.

Name ofthe verifi/ing officer

Designation

Date

Si ture with office seal