Professional Qualification Name of the Country Qualification Year of Institute Study INSURANCE INSTITUTE OF INDIA MUMBAI INDIA AIII 04.04.1997 Working Experience Name of the Nature of Business Designation Description of Period Employer Duties LIC INSURANCE MANAGER ADMIN/MARKETING 37 YRS List Of Specified Persons who will be responsible for Soliciting And Procuring Insurance Business Name Address PAN/ ADHA Qualification Details of Exam pass Certificate issued by R No. (Including Respon Insurance sibilities Examination Body as per Regulations ment SHANMUKAPPA #79/2,SILVER AWZPS8922Q M Com NA ALL BANK C000045810 GOWDA HV JUBILEE ACTIVITIES BUILDING,P B DECLARATION (This declaration is to be signed by two of the directors, two of the partners as the case may be) I/We hereby apply for registration. I/We have gone through the Insurance Regulatory and Development Authority of India (Registration of Corporate Agents) Regulations, 2015 and am/are satisfied that I/We am/are eligible to apply for the corporate agency registration. I/We state that I/We have truthfully and fully answered the questions above and provided all the information which might reasonably be considered relevant for the purposes of my/our registration. I/We declare that the information supplied in the application form is complete and correct. I/We undertake that I/We shall not allow or offer to allow, either directly or indirectly, as an inducement to any person, any rebate of the whole or part of the remuneration earned by me/us during the registration period. I/We undertake to service the run-off business on the books at the time of cancellation or non- renewal of registration. I/We declare that I/we do not possess an insurance agent license or insurance broker registration or any other license/registration issued by the Authority. For and on behalf of
Professional Qualification Name of the Institute Country Qualification Year of Study INSURANCE INSTITUTE OF INDIA MUMBAI INDIA AIII 04.04.1997 Working Experience Name of the Employer Nature of Business Designation Description of Duties Period LIC INSURANCE MANAGER ADMIN/MARKETING 37 YRS List Of Specified Persons who will be responsible for Soliciting And Procuring Insurance Business Name Address PAN/ ADHA R No. Qualification (Including Insurance ment Details of Respon sibilities Exam pass Certificate issued by Examination Body as per Regulations SHANMUKAPPA GOWDA HV #79/2,SILVER JUBILEE BUILDING,P B AWZPS8922Q M Com NA ALL BANK ACTIVITIES C000045810 DECLARATION (This declaration is to be signed by two of the directors, two of the partners as the case may be) I/We hereby apply for registration. I/We have gone through the Insurance Regulatory and Development Authority of India (Registration of Corporate Agents) Regulations, 2015 and am/are satisfied that I/We am/are eligible to apply for the corporate agency registration. I/We state that I/We have truthfully and fully answered the questions above and provided all the information which might reasonably be considered relevant for the purposes of my/our registration. I/We declare that the information supplied in the application form is complete and correct. I/We undertake that I/We shall not allow or offer to allow, either directly or indirectly, as an inducement to any person, any rebate of the whole or part of the remuneration earned by me/us during the registration period. I/We undertake to service the run-off business on the books at the time of cancellation or non- renewal of registration. I/We declare that I/we do not possess an insurance agent license or insurance broker registration or any other license/registration issued by the Authority. For and on behalf of
61085a0c-7107-4166-bc02-0313dfc8b724_IRDA%20Form%20A.docx