IRDA (Insurance Brokers) (Second Amendment) Regulations, 2013

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L.-33004/99 ( L h z ( S a x e t t e o f <3 n d i a o h I 3TOT*nT0T E X TR A O R D IN A R Y m T iii— 4 PA R T III— Section 4 grfferesrc ^ y ^ Tfgld PU B LIS H E D B Y A U T H O R IT Y 17. 39] ^ f% rfll,^srenT, VF&ft 13, 2013/TTre 24, 1934 No. 39]________________ N E W D E L H I, W E D N E S D A Y , F E B R U A R Y 13, 2013/M AGH A 24, 1934_____________ 7 TT>T^, 2013 41m s ftr feichitH HTfirarroT ( whrr ^ i m ) ( ^ f i t t w r ^ R ) M W t , 2013 •cftt. -R ^.fg-.f5T.UT./f^./6/64/2013.— gtaT RiPnmn* afrr »if«i«*.<ui atfaftriPT, 1999 (1999 w t 4 ) <sft otit 14 sfht arrrr 26 % ^rrer -qferr -tfWT ariqf^ nr, 1938 (1938 ^rr 4 ) «m r h 4 tt 'snm y^fr ^rferrat w tRTtrr -|tt yTfejTTOT ’{Tc'TFITcjnT l~H fd "^> TTT2T M < 1H V r"cfTT^ 41 !c; TTtT^STTT f-fIH fci Racl fa fn H H Id I % 3tsrf?^ :- l . ^tWt<r ynw 3#hr Tjrhr ( 1) % PafH-nn <Tim sfrrfecftra ctfwi aiareoc^srcT ^yffePT) ~fePraTT, 2013 «hg«iCf^ 1 (2 ) «»Ti I 2. 3TT%^TTTTiararc ( I ) 133 9 (3 ) ■f%^ri^ff<3fff%#n3;yld«ll(it<i Rb*)l :- "iffm cf?Y3ffr-$ v t w r s r t g r r th{^ 3f>rwvr Icntf) *fr «»*hhO jv « /5 w 3*r- fyfayv ( l ) 3&r (2 ) % d&Hfisn 3fdqrr yrt wrtt / <tt,tf=/i/Tarf vff tr&r tifivwcfrf) art I & 3Trni?r i k $ ~ n i } W f i l t h i U ) iff) H V & X T < H 3 I illf£r&7W 57 7T3 f f i / a fin*) <*? &ia*cicnni WhU I " s ngyq^ .7Tf ( ii) 'ftrf=:RnT io ( 1) % '*rr^ U,<* d-tii Rift^n 10 ( 13T) pHUTjwrr fwftw. r<*>A»T ^m i % tf/fifch V & ytrjct v s fm / 3iriiai, TfTenrr $ vft vfrorfa30 f^ r & 3f^r ^rr fafa<i* vft srj^yfr 1 $> aimf^r fei) tti) tSTff ^r/wrr fcnvi ■ jt 1^11 I 569 GI/2013 (1) i;,,t,{1 "f{o "tto-33004/99 REGD. NO. D. L.-33004/99 Ch-, ~l~Qil ~he <!:Jazette of ~ndia ~ EX1RAORDINARY 'WTIIl~4 PART III-Section 4 \Hft4cfii< ~ Q cfi I f?m, PUBLISHED BY AUTIIORITY li. 39) No. 39) ~ ~. ~. 'tfrnm 13, 2013/lmf 24, 1934 NEW DELHI, WEDNESDAY, FEBRUARY 13, 2013/MAGHA 24, 1934 .rir. f~i'l4'i"1t!fi ~ ~ ~ ~f14~+•Mi ~ . 7~,2013 "!fti:n rt.r-. .. 1i4t!fi ~ ftrcnm ~ (~ ~) (~ ~) ~. 2013 -q;r_ "fi. ~.ftf.fti.m./ftf.16/64/2013.-IO'lfT ·fa~ ~~J;11ll!llrl:or ~lf:lf.:l;qq, 1999 c 1999 ~ 4) <5t um 14 ~ um 26 i5 mw "lffcffl 1flirr anuf.nrq-, 1938 c 1938 ~ 4) ~ ·l!ITTT 114~ 1[m ~ ~ ~ w:rt'1T 11fiffl 111; !llmcfi<u11f\1n fflltl(Mil< ~fffi5mw"tt~l"l~f-cf>r-t-S~ i.(\'IG'._lll<I T-lwt~~fqf.i~·-.r-11i'1rt ~ :- 1. ~-;nif ~11'TN c 1) ~ -Fa~i:r'lf'riri faf.:IC11qo, ai'h--r.'R-t sufilo.<or l'lrl1U"<i["'n;r)C<;:~m tj~) ~. 2013 cti8"''~ 1 (2) ~~~it~~1llfill'Tfu:l"if'!,l'lnd'\'"itit I 2.~lf<"~ (I) "<ff.9(3) -f.ri::.mo!R§i'l"i5~·i;rRH¥-llflffl'fifi;qr~ :- •• ..,,,,. ~<Et-am- it-.tirr aflm17T...,. ~ lfi1'¥ an. 111W ~ .. 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RIRllfqcfi atl-(~ Sltrilifi(OI i;fflll afrl~ am~ ~ 8\<'11$(ltidf wref"m I ~1$~~ ~ ~ci'l~~UI ~ gq1u1q~ - I ~-~-"ffl I t-11,~~ ~ ~ci't~~UI <fit gq101q31 qllt'l!l'l.."f ~ : I (~~ ftlf.rtqq1c11l'fl. 2002 I pw~~-,,ifil~~~w;t I ~ I -.'r , .. I "ii' ,, I ll."i I ;;ft ,~ l &rt l ir 1-s 1~ 1~ I ll." I an I in 1~ lam 1~ I "i', 1, I 1ft ,~ 1~1 -int I• I HI$~ .. ~: I. itmf ,¥01\' ~cfi'Tt-11$~ .. ~, Piif.t«uqcfi JR~ sulilcfi<OI c~~, f'-f.t«.q1c:1~. 2002 l!litQT(T 13 ~ni'l'in fdlf.t«uqcfi ainflrclifff sulilcii<o, ~R.Jf.,4 ... 1999 (1999cfi'T4) * ~-1 Q,,n~am ~ o'cti~ ~~ fflQ. -t4'iJin f1fi"clf'il"Rl'Tt I 2. ,~<••·~ ct ~ ~~ cfil~'fcf.crr~ I 3. ~ t-1,,~ .. 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V V ~ 1f of l 2 3 -~ .. s 6 7 io -- ---- ~ - 20 THE GAZETTE OF INDIA : EXTRAORDINARY [Part III—Sec. 4] ------------------------------------------------------------------------------------------------------------------------------------------------------ ~~ fld.wc.(-11 8fflAll< ~'ifit1"" : 111fir~: t.Ntc.(-11 8fflR(I( ~ clfiT";fJq' : :lfrfif~: ~\.1•"<%.•<318'Wl q_cfiq1:11 ~ F.:c~¥1cfi / \.11"<%.I< l!fR: ~ : (~-""'8'-~ n - ~VTrnll cfilc.lf{'l4' cliT Rlcll<Oi ""''~~~ctc!fil'1«IT ~clfiT ~ ~ i ~F "qi" -u- ~;;..''"' cfi\'TJO'AT-..t . ~ : ~ ~ ~cfwt ~ ~~ <fil~ 'Tf V ~ S14'!Jffllfi'IR'lm""~ : Sl4'!Jffl lfi'I ~ : ~~<fil r - - qfh.m-w-1;; ~ ~ cfi\' ~,ct,~e,t '(511"""1"'1 ~ ?Et"di-0-0'.I <ff~ ~(~-ii" ('1f / -..fr} clfiT ~·-..tr'. m ~~cfi'r -· mw ~~ "'if w -,f .... - cht RicKUi [’TFT III— 4] *msT ^JT IF5m : 3TOT«^KnT 21 ~~1"'~1ll I ,. ~qiflTc5'R r ll"'ffl~ ~cfil ~~cti'r ~qfout•H # Cl31'<41\"1'<4 qif'Q'ffi ~ <:hl~ctl~l"4 ~'!Mr.f <fiW qi ~i:UH ~ ctilQft"IQ ~ it m~ ~'cfTT <ll ,~> ell,~> -mffl ~¥ qi' ~ "TT lf s Tl' tJ ~ . # '4~~--. .;, TtURT"ctil ~~~~am-« ~ ~~ n;IZice("f $«.U¼I< ~qif';fllf: ~/q~1q: ~~ 1$1Zice('1 $«.U¼t< ~qif';{N; ~/q~~,q: R~,l&i/~lfl~H a:refifT l(cfiql:il ~ R~¥1&i / ~lfj~I{ ~= ~: (~-1'lg"-cftf) I :::.:: ~1<'11 am,n-mlr g.;1a1ai'tlln11W~ °""~I 1::~-- # -:mt" "q'oT ~ ~3l-vl'~-mw - <fil~ -..rrtc'fi"U"{~ '11l1Tt? ~ / -;:rgl ~'l/[c en "{I' Tf 1 2 3 4 5 6 . 7 ~~ ·7T' 71iTTTrr'8T,-, rft~j;"wvrfiri-Tfit"llmr'ilftvfirm-rr.rc,rr Jngftr~ln'tnl-- : Jngftr ~f.(Q~ : ~mil~ "Q'JRJJriira;<fiJ ~liiqRqt~ 311'fR ( .f 1Qsl3.f trt 1 ~~lfrt) -g'f~ "Q" ~ ' .fcfl.f('lq~qtf ~~~cfil • TJtmvr ~ I I 0 "11 \ ( ~cfiT';fJlf: ~~: WR : -I>- ......, t3 I ~-~ --. ----. -arr-....r~ ~ .... "' ... 1Jif firnm: 1::- IIQ]ffl 15'1 nrt'ra : ~*lflitRlln'nTta'- : # VIISllil~ ~'S1l'l'lt¥~~~1i\"lt'lftffl'qtpf a'lfV!Ffi'S~'S~it :i~~, .. , .. ,,,..,,,,.., ... , .. 'If{~ atr.f ~ m. ~ ~ mw - Tiffrp: 1'i" w Tf 11 .. "f 1 2 3 4 5 ..... , .,.,..,.., 'llil~"QTIT ft'llfUTI : J. -.f'liif~lRmrllR5~ ("flsf':Nq 20~~'S~) ~~~ I 2. -;qt~~ •ae,ll 4i 100 11fiqi@ ... , ~If lf'imiff, ll8'~ltl'~* aID*~~,m-~ 1 -;ql ~ iit;w~~t. ll8' ~ a1llfif-a;~mn-~ft::ltt ~'F'~~ ~~· *~atfl~amv ~---&iii~ ~'llil~ : ., <!lfflir~ : ~=- lif◄zt'I l!4n-• ~11if-:mf : ~~: ~,~lJlftT~-.nifr ~~ 'lWR : ~: . I I ' ' 0 "T1 z 0 s: .... r ill SZ InilhiHte : fehtell life JJlih [> gnP)— III kih] I :~:: ~~lOI . 1--:: ~'st~ : ~~~mm~ : ~ •~~~~;jllql(l"l~~~~-h;"t-it'lu\f"M-q-~~ll'ml$~~'st.Jl'R't~ I # 'CSll'iT~ lfflT ~-ll"IIT ( 'Q,15 • .t.) .Jfln'S~it~lfit ll;l'i~i\'. ~~llfi 11;l'i • .t. ll'iT afll1lr lt. -rrt-um ~ ~~'st~ 1R'lrfiZ" l9i "9 Tf l1 s l ~ : l. ~cfi(OI flli 91011Ncfil< ('R'l'lR) ~-carit affifiwt I ~ 2. 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'--' # -.Sllil':f'l'lf antlfi'IT 11'@'~Jllfin 'Q;fflffl'~ uim ..,, 11.,,,.., 1"1T~23{ 2 }PT} tt'll'lftTr-~ ...... ,,., ........ llif,m;t;ffililn~ 'IRUl'fl'lfmtr CIT 1-;qf) 'RfrrF lli 'QI' "ff "Q' 1F' 1 2 3 4 s 6 7 -s~afn~alll~ ~'S~~ ~lliT':fTlf : '3'111'if/~ : ~'S~~ ~lliT':fTlf : '3'll1'if / ~ : ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ ~,~~~~ ~,~ laR : ~ =~~ri} I I t::l 28 THE GAZETTE OF INDIA : EXTRAORDINARY [ P a r t III— S ec. 4] 1 Is 1 6 ill i? Sv 11 # II* 1? 1 19 i i 6 t i 'j l i 1? 1**1! 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(~ 1 -➔ti) ~ f-il~~•<t? ~ ra:.~1fcllil t#qF en ~ '1T .,..fferr{ air( 3-1¥"1 am-11 ~ii6&f-ilc.l'i1~ ~c5T'-tllr : ~~ ; ~~Qsf,.,c:l-,~ ~ c5T'-tllr : '3'QTIQ" f'l«,f-lllf ; f-1@ lcti/ ~ 1$1 G 1 ._ a:re.rcrt"t~cli'lffil' 1411fr R~¥1ilii\41~~•< 34 THE GAZETTE OF INDIA : EXTRAORDINARY [ P a r t III— Sec. 4] 34 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III-SEC. 4] . i " i ~ i t .. ~ . ' I f 16 l " i .. J ii ~ ,ff 'f6 rr i ~ ! ~ ~ ~~ ·l 11! I J I J ~ l I ~ Ii ~ l I ~ 16 ~ ~: I ~ - i it! i ~ ~~ i J ~ rli ~Ii ! Iii ~i ~ ~i 1if t ,J 16 ..... ..... l f J ~~ J;;; ~; i ~ U' ~ U' ~ ' tf6 l ~! 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H $ ? , If K 1 i * 1 p 1 > ■I ? i n & ? i 4 * w i £ K |C I n & cE k 1® | H |w jv ! 3. a 7 I *- * 10 r 1 1s 1 h) B 0 \ ± p w E »- 15 i l l * \ M) 7 i 1? b | 19 i E »- 1? I n 1* E & I 1 lE h I P I c(t1 E * I n 1s 1 i IS l l 1 fa I f I I 46 THE GAZETTE OF INDIA : EXTRAORDINARY - - ~ ~ • l l 1 i ~ 119 l\f ·~ ~ 119 ~ ~ ~ I~ ~ rl.1- + 'Ii ~ ~ I I :-i ~ ~ ~ J;' Ii I;" + " ·+ flt ~I~ ~ ' ~ + i j.. ~ ! jii~ ~ ' I i ,- 119 l !<ii ~i i .f ~ I I l .. ~ l t' •' N ! l .. ~ ' I 3 i .f Iii- f , .. r; ! ti .ft I i, ' i .. I?' i !<ii ~i i .1 I,)) J-l ' ii!: .. ~ ~ jii f I;' ,I& I I ' ~ ti! .. ~ , · tii j 16 I I ! Ir, .. - f 1 .. f ~ i i 16 i .. ; [PART III-SEC. 4] - - J. { f 2 i i; ! ,I& i ! i ,l6 I i ~ >-- i I-- ' - >-- I I, >-- :: i - I '-- I - i '-- 1 i ~ f - ~ Ii l .. l i lllll T l1'1' T ,.,. T ,.,. T 'htil T T1'1' T l1'1' T 1-,. T lfiTVQQT ~ ~ ~ ~ ~ ~ ~ ~ «NF 1'i" w 'fl V .. .. V ~ 1f ,;r "Z" c5" ~ .... 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(ytjri jftfiT<rcr%3twr<TR)-vft«fw 10 yi#* ( - 31 48 THE GAZETTE OF INDIA : EXTRAORDINARY [ P a r t III—-Sec. 4] « I f I * is i ? 7 Iff ii 1s ‘5 I 15 Ik | I II I t r.'+ * 5 ,‘5- I l11WS-'111't1111nmf.-_ari!Qon:il flfiprq~amm:1">-11l'lim1 10,;i1"!1i c-:i\1R- a1~>, • ~-':WII' ~ 111naf+~ »-- c-~·-..... ~ ~l,, • ..,,_.., ) W1'Wlt+1i1Vfflf ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ l<ifr l l'IS't l l..ft l l'ltr l lcli't l 1t9lrT 1t9lrT ~ 1t9lrT 1tUIIT 'Rlrr~ ~ ll' TT 11 1F "' • "' • 41' .,~ l - -sft.n( ~~ amu ~-i; aiNteH &fflh(H ~(fil-;n'lf: ~/q~1q: - 3114~ 'S fisNIZl-1 6fflR(H ~~-;n'lf: ~/q~111: Reyu.fi/-Et•~~I< aMcfT t(cfi111~ mm R~,lcti/-Etlj'lc:.1< 1'!JR: . . ,. - . aJliq ~~ ~ 1ffl\lfflN ]flfllVL ~ ffl1'II" llh7' l llh7' T 'ffll!ff ~ ~ c5" ... • -, ~ l ,, • ..,~,_~,) ~ ~ llll\' l ~ VT lf 'llffl'lflm'lfi'rp1tUIIT ~ pftirn 111\'p 1t9rr • ~ . .. lf>t.~ ~'9+~.;f +W+~~ ·+~+~ ... • I -l s 0 ► N tTl ::j tTl 0 'Tl /3 a - 1-q;r,f 1(ff (./t,r-r) : 1i\irr ~;;m:il ~ R't1!; '"Iii~ I 'I ~ ~ (~ ,i\q lifi~ f) - I 1~:: ~ : ~~ll'rtnw : I ~lliT~ : ~-~f.llfflwrtnw : I ~li'lln~- ~llQlAIT'ff I ~ - (1j~cfi oQq(ijcf # .. ,..,~, ..... oQdl\114 oQdl\itQ<fi\"~ ;,;-......... ~ ~~~ ~lfiT - silf.:i4q .. ,,¥1 ~ ... ~~ °'ill'l:ll~qf'ifil '"'l'il'fH"I "IICll• 11 GS"ll~I~~ -mffl ~ qft~ ~ t#fl'F <ti ~ "" 'tT ~ ~ lJ" -ii" 'tl=(1Tnl']* 100 -if=[U"R:tJ* I 00 ~ ~ ~ ~ ~ ~ amq ~ ~ ~ ~+~ t"IT11~ d4:11 f.a'-" ~+-31,l~ftl t"IT11~ ~ t"IT11~ 31;q' ( .;, .. ...,_.;,) t"IT11~ ~ 0 0 0 0 0 0 0 0 ••apfcftt',ofq <1111cn1"cfi1'"uit-?cn._ ~.;, q,1.,"11,._ ~f I 50 THE GAZETTE OF INDIA : EXTRAORDINARY [P art III—Se c . 4] [? ■V. 6iy cl 3114 ~Qi diT ';fl1J : - dfla~ ~ fi;f;jje<"f g~IS:i< -3 :r: tr1 C) > N tr1 ~ tr1 0 'Tl z 0 > tr1 · X ~ 0 § z ► -, ~ 00 -4 ON l/l ■U u> N> M * it5’ 2' 2’ £. ± t 1 5/H f 1 1 1 1 1 1 4 4 l a, (S) 1 1 jcJF 1* ©o 4 f 1 1 i * 9P I " I t £ s' <rt' is inilhim£ : EhM> life, irnh [1? gnis>—ni Wh] I """'1% rik:--.ikr-r,1 I : '"1lf ~I.ii ai furo; ""~~ l'I a;" ~ (-IR-""'R ,i\q l<l;ilf) - r-, 1 1-.:: ~ : '!n(Jffl~~ : I ~ ~f.w.f~ : I ll('QIJlfrqr~ - -IR-~~ I # 6Qd.(-11q<frr~ q,f<"lm41 arr !flfo qq arr-um ~\"'!•~•-« amr "> ~ ~i<."11 SI d¥1d ~ "ffiw¥ cli' ~ TT ~ ~= ["7T n:sr] * I 00 1 lRR'~ 2 lRR'cliTm 3 ~ 4 "'Qii<i'{ 5 ~.~ . -- -- 6 l? ... ,,, ... <u, .. , -- ,_ 7 <."11~IGll1\"1C:.I 8 filRt~..-i~-tt . I 52 THE GAZETTE OF INDIA EXTRAORDINARY [P art 111—S e c. 4] \S /■& V 8 :il tTl Cl ~ tTl ::j tTl ~ z 0 > [* m r h i — 4 ] t ^KcT gn TTSPT? : STCTTmTOT 53 Iff f t 1 1 11 f Hs .. 9 ■i '6 '1 ■v Iff Jff Iff * 15 Iff I & I ft HS f i I i i --~---------- ----------· ~cfiT';{llf ;, .. , .. ,,-,<fil~ ~"lW r ~~ -·· ~ ~ -· ci;q;ft~ # l@T )ii <,n1 ,:;n I I -1 C., ,_. I ,:;n ~ ,. ~~llif~ ".gJ'?.ffur<fil~ cfil44iHIQ cfiT (~ : ~"i1ili) ~ (~:tcR:r ~ «/JT<ffc en ~ "TT "Q' s 1 2 3 54 THE GAZETTE OF INDIA : EXTRAORDINARY [Part III— Sec. 4] 54 THE GAZETTE OF INDIA : EXTRAORDINARY [PART Ill-SEC. 4] - i ~ ~lj:r !tf ii 1h Ir ,c, Iii i ! If i j I I I { t I r ~j ~,161~ i i U;ifj Ii I 'j !i"itt : j ~ 7 .... ; j 'f6 ~ ~ ; T Ji ~i ! !1if i i Ht : I ,, ~ .., ~ ; ~ ., - -,. t ~--t w J li i fitt l j~, . j ~I{ IP l " ,16 i ' 1 1H*t i i ~ ~- I l I I ~it t ~ Iuh i j ~ J {11 ; ~ ' t ~ l -- lh I ,16 I :{ i IP 1! ' ~ f.; , - .., it ~ l I l if I i !, ~1 fu i ff ~1 i i j ~ li ! n ~ ~ ~ t i t ~ ' ~ [H P T I I I — 1 3 * 5 4 ] /iff 55 * is rirT 'v. &rV •v vr / 3v * V /tf I r S ' ---------------------------------------...-----------..... --------- ,...., .is. L....J 56 THE GAZETTE OF INDIA : EXTRAORDINARY [P art III—S ec. 4] INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY NOTIFICATION Hyderabad, the 7th February, 2013 Insurance Regulatory and Development Authority (Insurance Brokers) (Second Amendment) Regulations, 2013 F. No. IRDA/Reg/6/64/2013.— In exercise of the powers conferred by section 114A o f the Insurance Act, 1938 (4 of 1938) read with sections 14 and 26 of the Insurance Regulatory and Development Authority Act, 1999 (4 of 1999), the Authority in consultation with the Insurance Advisory Committee, hereby makes the following regulations, namely:- 1. Short title and commencement (1) These regulations may be called the Insurance Regulatory and Development Authority (Insurance Brokers) (Second Amendment) Regulations, 2013 (2) They shall come into force on the date o f their publication in the Official Gazette. 2. Consideration of Application (i) Clause 9(3) shall be substituted for the following:- “A ny employee responsible fo r soliciting and procuring insurance business on b ehalf o f an insurance broker shall also have to fu lfill the requirement mentioned in sub-regulations (1) and (2) above, a list o f such employees needs to be provided to the Authority in fo rm E provided under Schedule I to these regulations and acknowledged by it ” Requirement of Capital (ii) A new Regulation 10 (1 A) is inserted after Regulation 10(1) as under 10(1 A) an insurance broker shall provide information regarding its capital structure and details o f shareholding annually on or before 3(fh June o f every year. Further, any change in capital structure will be reported within 30 days in Form O provided under Schedule I to this regulation. Renewal of license (iii) Under regulation 13 (4) the words ‘Form B ’ is substituted with “Form C provided under Schedule I to this Regulation” Effect of refusal to grant license (iv) Under Regulation 15, the words “Regulation 13(2)” is substituted with “Regulation 14(2)” Issue of a duplicate license (v) Regulation 16(1) the word “in the prescribed fo rm given in schedule I ” shall be added after an application Under Regulation 16 (2) the words “in Form B ” is substituted with “in Form R provided under Schedule I to this regulation ” 56 THE GAZETTE OF INDIA : EXTRAORDINARY INSURANCE REGULATORY AND DEVELOP.MENT AUTHORITY NITTIFICATION Hyderabad, the 7th February, 2013 Insurance Regulatory and Development Authority (Insurance Brokers) (Second Amendment) Regulations, 2013 [PART III-SEC. 4] F. No. IRDA/Reg/6/64/2013.-in exercise of the powers conferred by section 114A of the Insurance Act, 1938 (4 of 1938) read with sections 14 and 26 of the Insurance Regulatory and Development Authority Act, 1999 ( 4 of 1999), the Authority in consultation with the Insurance Advisory Committee, hereby makes the following regulations, namely:- 1. Short title and commencement (1) These regulations may be called the Insurance Regulatory and Development Authority (Insurance Brokers) (Second Amendment) Regulations, 2013 (2) They shall come into force on the date of their publication in the Official Gazette. 2. Consideration of Application (i) Clause 9(3) shall be substituted for the following:- "Any employee responsible for soliciting and procuring insurance business on behalf of an insurance broker shall also have to fulfill the requirement mentioned in sub-regulations (I) and (2) above, a list of such employees needs to be provided to the Authority in form E provided under Schedule I to these regulations and acknowledged by it. " Requirement of Capital (ii) A new Regulation 10 (IA) is inserted after Regulation 10(1) as under JO(IA) an insurance broker shall provide information regarding its capital structure and details of shareholding annually on or before 3(/h June of every year. Further, any change in capital structure will be reported within 30 days in Form O provided under Schedule I to this regulation. Renewal of license (iii) Under regulation 13 (4) the words 'Form B' is substituted with "Form C provided under Schedule I to this Regulation" Effect of refusal to grant license (iv) Under Regulation 15, the words "Regulation 13(2)" is substituted with "Regulation 14(2)" Issue of a duplicate license (v) Regulation 16(1) the word "in the prescribed form given in schedule I" shall be added after an application Under Regulation 16 (2) the words "in Form B" is substituted with "in Form R provided under Schedule I to this regulation" ' . [HPT III— * 3 ^ 4 ] < HTCT TP5R3T : 57 Deposit Requirements (vi) After Regulation 22(1), a new Regulation 22 (1A) is inserted as follows. “Details o f such fix e d deposit shall be furn ish ed in Form I provided under Schedule I to this regulation ” Maintenance of books of account, records, etc. (vii) Under regulation 25 (2) after the words auditors report the following words is added ‘including details regarding PAN, D IN and declaration ’ Disclosure to the Authority (viii) A new Regulation 28(2) is inserted after Regulation 28(1) as under ‘An insurance broker shall furnish the following in respective forms (as specified below) provided under Schedule I to this regulation a. Audit arrangements in Form D b. information about registered and branch offices at the time o f grant o f license/ renewal/whenever an office is opened or closed in Form F c. the standing arrangement with other brokers or service providers in Form G d. spread o f business during the year ending in Form H e. insurance Bank Accounts may be submitted in Form J f professional Indemnity Insurance in force in Form K g. the claims data in Form L h. reinsurance balances outstanding in Form M ' i. security screening proceedings for reinsurance broking in Form N j. board o f Directors/ Partners, and management details in Form P k. financial data o f brokers in Form Q I. business particulars o f brokers in Form S m. organization structure in Form T n. reinsurance business details in Form V J. HAR1 NARAYAN, Chairman [ADVT. 111/4/161/12/Exty.] — / 5 * [ 'IWI III--~ 4] 57 Deposit Requirements (vi) After Regulation 22()), a new Regulation 22 (IA) is inserted as follows. "Details of such fixed deposit shall be furnished in Form I provided under Schedule I to this regulation" Maintenance of books of account, records, etc. (vii) Under regulation 25 (2) after the words auditors report the following words is added 'including details regarding PAN, DIN and declaration' Disclosure to the Authority (viii) A new Regulation 28(2) is inserted after Regulation 28(1) as under 'An insurance broker shall furnish the following in respective forms (as specified below) provided under Schedule I to this regulation •. a. Audit arrangements in Form D b. information about registered and branch offices at the time of grant of license/ renewal/whenever an office is opened or closed in Form F c. the standing arrangement with other brokers or service providers in Form G d. spread of business during the year ending in Form H e. insurance Bank Accounts may be submitted in Form J f professional Indemnity Insurance in force in Form K g. the claims data in Form L h. reinsurance balances outstanding in Form M ' i. security screening proceedings for reinsurance broking in Form N j. board of Directors/ Partners, and management details in Form P k. financial data of brokers in Form Q I. business particulars of brokers in Form S m. organization structure in Form T n. reinsurance business details in Form U / J. HARi NARAYAN, Chainnan [ADVT. lll/4/161/12/Exty.] THE GAZETTE OF INDIA : EXTRAORDINARY [P art III—S ec. 4] 1 Js L i ! n i l - - ■HI SCHEDULE I- FORM A '~ L.A..:..P;,;_PU ..:..CA .:.:..;.;T:..:.JO = N~ FOR =-..:..;_..= G.:..: RA :....:.N :..:.T.:......;;;, O ;_ F .:;; Ll..= C=.: EN..:..C=-=E;!,./ ..:.. RE= N.:..:E:....:.W..:..:A.:.:.L::..:O= F....:L:.:..IC.:..:E_N....:C:..:.E _________________________ ~--------·----_J lfflDOftallt tnstrucuons: - ... u,atoty And Dowlof>mont Alllhonty (lruurance Brohn) R .. ulltJOns, 2007 APf'llCAJIOH rOM GIIANT OF OC(NC[/lt[N(W~L or UC[, Schedule I (Form A) ,,,__ Print or Tr,,. Olo,om,,s m In ?Tito/ L,ntt1 [H If , (11!p! '1 01,E,ill a t Ill I H1¥1 iL:J..o 1 , ::::nIT !\ l ~ I i I u I v IN I x I Y I c I Note: l tt Ill l~nt ~t be'ort this ipplClbon fotM ft f,!~ i"• U'le reau1at1ons made b, fhe 4uthoor;, .. ,. ~wcfi@d CIMtfully l ~t, ""''' \.UOffl•• 1 duly completed • ppl,0~01 la,"' 1aatlh~ ""'1't Ilk _.-nprwre, &wpPD'1J•-c doa.m.-nt, to the A,uthontv 3 App,l~k,n fot -.c:rna- WtlA bit~ Ol'4',' ff ft. 11 mmptel:•.,, d rnpech. 4 Af)pliQffl v,cuW I.Cf' tN! aoouc anons memse1ve.s '!tw.fomiift,att nfltlid:IIObe:11,11 lin ,nof~ ftlaik OTJ•Y le 11v.r, on M~1 wt,od, ~ fd bP •!1-.dwd to the ap~llor\ fa,m ,1 I\ not • ptop,ICl.t"' '• •''""' 0/lf a O"ll'"1,.,.,.Y, tht 1t1f0tmii1.uo.,, '°' '" fhit • or,,, ihef bto tuppl1ff Current LiCfflStl Oeta-ai. (If AppliaJb~ J License No. M:Ji ! ! ! ! l .! l Et •°"')' p -H~newa1 01JtJ/1c c r,or, License Issue Date !&IP I ¥IM j Y ! Y I YI YI License category 0 1 ~tmt of th t appllu:t,t 11111111111111 i< 1111111 l:fi t II IHl ., -l ::c tT1 C) ~ tT1 ~ 0 .,, z 0 ► tT1 ><! -i ~ 0 :::0 0 z ► ~ '=a ; = T Vl 0 ~ 1III ft 11il ;|HiI IIfl1*W>•■m m #is>iW'~1 1! i lill iiil n il If ‘y- ■iIi _ _ _~ II . _ Vr*. _:.... ; .=sirI ■■■ —.r- z - ~r L^_ _.— — ..... : T ~„- —* _ 1 __ f t- _ ’ ~r ■ _ r —1 __~_ 3 __ _ _L __—_— i H I a I i f I ,i i, t,r: _j Q Jt...; . ,, ,, ' l; ,; i 0 l C !! C 5 " f g :: , i ; ~ ! ·o ; u s j } . r . f; ~ & C 3 !: .; : I u ~ V 0: V 6 "' ~ .. 0 0 0 -FF ■ ~ r- 131=1 El = 2. Organization Structure 2.1 Status of applicant Stock exchange (optional) Latest Share Price (Optional) 2.2 Date & Place o f incorporation Date Place 8 — ME smugs u M M B M Lg jfe M A I H v I v.l y I ■ ■B E 2.3 Scope of business as described in the Memorandum o f Association (To be given in brief and only attach scanned pages contain mg Main objects and authorized paid up capital from Memorandum and Articles o f Association or Partnership Deed.) 2.4 List of All shareholders (holding 5% and above of applicant directly or along with associates-applicabie only to limited companies) Name of Shareholder Column Code No. o f Shares held• •- a % age o f total paid up capital of the company Foreign Holding (Yes/N o). b • ' - ■. c ■ ■■■■■■■■I H HHHB 1 ■ ■ I ■ ■■■■■■■■HflHNiiMiaiiiNiiiiiMiiHii warn i h * i ■ i f ■ ■ m ■■ s ■H 1 ■ ■ H ■ |HI 1 41 IB 1 ■; 1H 1 ■■ I HI 1 ■ ■ ■ ■ ■ ^^^B >.v WU BH B B ■■■■MttBKfflHMIIlHattHHilfelittBlMriHdWHMtaMiHIUiMMAriU ' I ■■■ 2.5 Particulars of Directors/Partners/ Propeitors Experience ininsurance Broking Share in applicant firm /company Directorship s other companies services and related areas THE GAZETTE OF INDIA : EXTRAORDINARY [P art III— S e c . 4] 2. Organization Structure 2.1 Statu:s of applicant Ill Stock e,ichanee (optional) Latest Share Price (Optional) 2.2 Date & Place of incorporation Date Place 2.3 Scope of business as described in the Memorandum of Association (To !Je given in Nief :!Ind only attach scanned p.ages con1:aimng Mafn objects and authori:.ed paid up capital from Memorandum and Artkl!:'5 of As:sociatior. or Partnership Deed.! 2.4 List of All shareholders (holding 5% and above of applkant directly or along with associates-applicable only to limited companies) ShliteftOkfln& •• on datt Name of Shareholder No, of Shares h~d ~ age of totn.l paid up capital of thatompany Fore-tgn Holdlr\g (Yes/No) Column Code a b c ~ --I----------------+------------~ .~ (:L 1 I 7-- I I . - ------ - ---~ j~·- -- - - ----------- --- - - - - ----=.---''-- - ---------- ----- - ----- 2.5 Particulars of Directors/Partners/ Propeitors r--r-,·---, , , ffi s; ~ 0 'Tl z g > [■RFT III—'m z 4 ] ^RcT ^Tl TT3TO : 3renm FT 61 2.6 Name of activities carried out by the associated company/concerns Name of the company or firm u Nature of interest of the Type of activity handled . Nature and interest o f applicant company promoters/directors Whether any one or more persons of the associate companies/ concerns are interested in the applicant's business. 2.7 Name and Address of the Principal bankers of the applicant i Name of the banker ■ , ■■if-. __- .. — ... ■ •.. — :. Hi ------- _ -- - - - __ ii Address Address 1 Address 2 Address 3 City District State Country Pin Code •..”, " s * t ^ ■ . ‘ ■ . : , ■ ' .f ■ ■ ' ' : ' r~ n ~ F -o ..m m r I I lUTTTvf: I:-. r i ..i.. i„ i..i..l j j 2.8 3.4 Details of infrastructure like office space, equipment and manpower available with the applicant Name and Address of the Statuatory Auditor of the applicant Name of the Statutory Auditor 3.5 Details of experience in insurance broking/ insurance consulting/risk management and other services: (History, major events and present activities (Experience outside India may also be indicated): «A ttach scanned document if required» 3.6 Business handled during the last three years with insurers and list of reinsurers with whom more than ten percent of the total reinsurance premium handled, was placed. [ 'lWT III-~ 4] 'qK"cf cfil ~ : 3lBJ'tffiUI 61 2.6 Name of activities carried out by the associated company/concerns Addrft, Type ol activity handled N,,ture of interest: of fhe Nature and interest of apphcant company Name of 1hc company or 111 m promoters/directors f-- ---- - -+-----+----- --------+-----1------- e----,---t------+----------+--- - - - -+---------, Whether any one or more persons of tl11!!! associatl!! companies/ concerns are interested in the applic.mt's business 2.7 Name and Address of the Principal bankers of the applicant i Name of the banker Hf I 111 U 11111 -- 11 I I 111111111111111 ii Address Address 1 Address 2 Address 3 ITT 11111111111 ·· 11 1111111111111 ~111 City District LL 1 1 sk r-1 1 , , 1 , 1 , l I State Country PlnCade I I I ) l ) fJ, k j 2.B Name and Address of the Statuatory Auditor of the applicant ................. ,... 1111111111111 t. 11 d I ! i 111 i I i ! i -t 111 i 3.4 Details of infrastructure like office space, equipment and manpower available with the applicant 3.S Details of experience In insurance broking/ insurance consulting/risk management and other services: (History, major events and present activities (Experience outside India may also be indicated): .-:-:Attach scanned document if reguirecl ►> 3.6 Business handled during the last three years with insurers iilnd list of reinsurers with whom more than ten percent of the total reinsurance premium handled, was placed. 62 THE GAZETTE OF INDIA : EXTRAORDINARY [P art III— S e c . 4] SI. No. # Name Amount Premium Handled % of total premium handled by the broker Service Rendered -Mstah b ■ I H ■ ■ ■ ■ ■ ■ H W f l ■ ■ H H H U U U h b ' H H i H I H H M H H H U H I H I N t a ^ B H H H I ■ ■ ■M l f e l i f t M t t l l H i l l f l l M M M N M I H H H ■ ■ ■ ■ m M H H H H s ? f l H ■ 1 */■ . > ■ i H U ■ ■ ■ M U H t a i 3.7 Any other information considered relevant to the nature of services rendered by the applicant. B M i S I | . .. ... . T ,r . . 1'V i'; ___ J 2 H ' , trf'y? *> ■ TOW pip*lv. I S I W i lkilfe.vai'3 ‘ * : : 3. Business Information . ’ 3.1 Three years business plan document with projected volume of activities and income (including anticipated) for which licence sought is to be specifically given. «A ttach scanned business plan docum ent» V - SUE3E ,.r.. v. .......... ...' ■ ' ,V • ’ • ‘ ‘ ________ ._________ _______________ L _ ! 3.2 Organisation Chart separately showing functional responsibilities to be enclosed. «A ttach scanned document or pr«sen tation» 3.3 Particulars of key management personnel Name Qualification Experience with particular reference to Insurance Broking/insurance Date of appointment Functional Areas ■■■d M H ■■ MM ■H H H H ii Hi ■ ■■ ■ HIM■B Mnas ■ , - lL\ ■ H I ■feiHBkllimiHHHHBHHHHI 1 . - HI - {■■■■■■■■■■■■I M H N M M 62 THE GAZETTE OF INDIA EXTRAORDINARY [PART III-SEC. 4] 3.7 Any other Information considered rele1,1ant to the natur@ of services ren dered by the applicant. AddftUl Add...-n, l llHlflilHI II It 1 111 1 111111 11 11 ct 3. Business Information 3.1 Three years business plan document with profectl!d volume of actlvitiu ind income {includln1 antlclp1ted) for which llcence sou1ht is to be specifically 1Nen. «Attach sunned busineH silan docu1nen1» 3.2 Or1anisatlon Chart separatety showln1 funC1lonal responsibilities to be enclosed. «Attach scanned document or p~,:!senta1ion>> 3.3 Particulars of key mana1ement personnel Name Quatlf,atton Eicperaet1ce with particular reference to ln1umnce Brokmg/msuranw __J [^IFT III— '* 3 ^ 4 ] 63 4. Financial Information 4.1 Capital Structure ___________ __________________________________________________________________________________________________ Rs In Lakhs Capital Structure Year prior to preceding year Preceding year Current Year a) Authorized Capital b) issue Capital c) Paid up Capital «R e fe r Form 10 - Deductible validation» d) Free reserves ( excluding revaluation reserves) e) C+D (paid up + free reserves) Note:- 1. In case of partnership or proprietary concerns, please indicate capital minus drawings and/or loans to partners/ owners. 2. In case of partnership or proprietary concerns, please Indicate the financial position, means and net worth of the partners. 4.2 Deployment of Resources __________________________________ ___________________________________________________________Rs In Lakhs Particulars Year prior to preceding year Preceding year Current Year a) Fixed Assets b) Plant & Machinery c) Office Equipment d) Quoted Investments e) Unquoted Investments e) Details of Liquid Assets f) Others (Details of Investments, Loans & Advances made to Associate Companies/Firms where Promoters/Directors have an interest is to be separately given). 4.3 Major Source of Income «Applicable for renewals - a) and b) only,others applicable for a ! l » <n Lakhs Particulars Year prior to preceding year Preceeding Year Remuneration received as percentage of premium a) Direct insurance remuneration b) Reinsurance Remuneration c) Advisory fees d) Insurance Consultancy e) Investment Income f) Others • As remuneration received by the insurance broker may vary from risk to risk, please indicate range within which remuneration has been received. 4.4 Income and Profit before tax Income Profit Before Tax Year prior to the preceding year of current year Preceeding Year 4.5 Dividends Particulars Year prior to the preceding year of current year Preceeding Year Current Year a) Amount b) Percentage Note : Please enclose three years audited annual accounts. Where unaudited reports are submitted, give reasons. If minimum capital requirement has been met after last audited annual accounts, audited statement of accounts for the period ending on a iater date should also be submitted. [ 'lWT III-~ 4] 4. Financial Information 4.1 capital Structure --- ------ -------- -- Capital Strut lure Y~ar prior to procecling yaar Prnceding ~8ar Current Yea, =i) Authorized Capital bl l:m1e c:aplti!tl c) Pilld up Capital «Refer Form 10 - Deduct!ble validation>> d) Free reserves ( e1Ccludlng revaluation reserves) e) C+O (paid up t free reserves) Note:- 1. In case of partnership or proprietary concerns, please indicate capital minus drawings and/or loans to partners/ owners. 2. In case of partners hip or proprietary concerns, please Indicate the financial position, means and net worth of the partners. 4.2 01ployment of Resources Particulars Year prior to preceding year Preceding year .i) FIMed Assets bl Plant & Machinery c) Office Equipment d) Quoted Investments e) Unquoted Investments e) Details of Liquid As sets f) Others (Details of Investments, Loa ns & Advances made to Associate Companies/Firms where Promoters/Directors have an Interest Is to be separately given), 4.3 Major Source of Income <<Applicable for renewRls - a) and bJ on!y,others appllcable for all>> Current Year 63 Rs In Lakhs Rs In Lakhs Its In Lokhs PartlCulars Vear pnor to precechng year Preceedin9 Year RemunPration ret.eived as percentage of premium a) Direct insurance remuneration b) Reinsurance Remuneration c} Advisory fees d) Insurance Consultanc1r el Investment Income f) Others • As r1muneration received by the insurance broker may vary from risk to risk, please indicate range within w hich r1muneratlon has been received. 4 4 Income and Profit before tax ... ... .. -. lncornP Pr~f1t Before T:ii• Ye.:11, prior to thFI prHPding Vf!Br ol cunent yaar Preceedmg Year , ,,,,, ,,, ,, A1 4.5 Di\lfdends PartlCUlars Viar prior to the preceding ~ar of current year Preceedm9 Year CurrPnt Year a) Amount b) Percentase Note : Please enclose three years audited annual accounts. Where unaudited reports are submitted, give reasons lf minimum capital requirement has been met after last audited annual accounts, audited statement of ilccounts for the period ending on a lilter date should also be submitted. 5. Other Information, if any 5.1 Details of all settled and pending disputes: ■1 Nature of Dispute________________________ Name o f the party ______________________ _______________________ Pending/ settled P HiHHHHHHi ■ ■ m m m m m w a r n I k 4 f l M m 5.2 Details, if any of any economic offences by the applicant/ proprietor or any of the Partners/ Directors, or key managerial Personnel in the last three years. ' 6. Document Checklist Document Checklist Document Required Uploaded Document Name V DocNamel Attach xxx.doc Remove V DocName2 Attach xxx.jpg Remove DocName3 Attach 7. Fee Payment A rton-refundatjie fee of Rs. Xx,xxx (depending on Broker Category selected in section G.3 above "Category Applied For”) will need to be D3id to IRDA via the e- payment options displayed to applicant on submitting the online application form. 8. Undertaking 8.1 Whether any person related to applicant has been refused for the License in the Past or N o t. Name o f the Persons Relationship with the Applicant Training D etail F or the purposes o f this sub-clause, the expression "directly o r indirectly connected" means a relative in the case o f an individual, and in the case o f a firm o r a company o r a body corporate, art associate, a subsidiary, an interconnected undertaking or a group company o f the applicant 8.2 Qualfication and Experience details o f the Principal Officer of the applicant ..% Name Address Qualification (including passing Insurance Broker Exam) Prior Experience (including Insurance Industry) Previous Employmant Employment Details 8.3 List o f employees who will be responsible for soliciting and procuring insurance business Name Address Designation Qualification (including passing insurance Broker Details o f the Responsibilities THE GAZETTE OF INDIA : EXTRAORDINARY [ P a r t III— S e c . 4] 5. Other Information, if any 5.1 □,tails of alt s,ttled and pi!nding disputes· I AN .... l¾ L S.2 De!aits, if any of any economic offences by the applicant/ proprietor or any of the Partners/ Directors, or key managerial Personnel in the last three years. - 6. Document Checklist ✓ ✓ 7. Fee Payment Document Required I DocName1 DocName2 DocName3 Documenl CheckliS1 Uploaded Document Name xxx.doc xxx.jpg Remove Remove lutibhef.lt I A rKJr••r~for.dut>!e fc~ of~~- Xii,JOIX !depo!ndini; on Srokc"1 Category s~ie-cted in section G.3 above ftCdtt.'gory Applied For"J will nt.>ed lob~ oakt to IRDA via Uii? e-paynnmt option!i di-splc1yed to ap?iif:ant rm !iurln,ittint=; thll! cnline .applicaticin forn, 8. Undertaking 8.1 Whether any person related 10 applicant has been rehised for the License In tile Past or Not. N;::ime of the Persons Rell'ltionship with the Applicant lraining Oetalk For the /Jlfl1HJ.'il!s ,if this .,uh-clausl!, the aprei,;sirm "ditect(v or indir1t,:tly com,et.:ted" nu,:ons a n.•/ntil'e in the case uf cm mdi\';dual, and in the case r!f a firm or a company or a hody corporate. an o.uoe/ate. a mh.,;idiary. an interconnec:,ed 11ndertaking or a group company ofthe applicant S.2 Qua1fication and E11~erience delails of the Principal Officer of the applicant Name Address Qualification {including passing Insurance Broker E1t2m) 8.3 List of employees who will be responsible for soliciting and procuring Insurance business Name Address Dlflsignation . Prior E11.p,erience iinduding Insurance ;ndu:stryj QoaDtication (including pas:sing lnsllrance Srok(!r Prewlou:s Employment Dctai~ of lh~ REJpOMibilitie-s Employment Details 8.4 Details o f the fixed deposit for renewal of license Name of the Bank Address F.D.Numfeer Amount HeW in Deposit Percentage to initial Capital Maturity Date ‘ 9. Declaration J THIS DECLARATION IS TO BE SIGNED BY TWO OF THE DIRECTORS, TWO OF THE PARTNERS OR THE SOLE PROPRIETOR AS THE CASE MAY BE. I/We hereby apply for licence. I/We have gone through the Insurance Regulatory and Development Authority (Insurance Brokers) Regulations, 2002 and am/are satisfied that 1/ W e am/ are eligible to apply for the insurance broker's licence. 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 licence. 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 licence period. I/We undertake to service the run-off business on the books at the time of cancellation or non renewal of licence. I/We declare that I/we do not possess an insurance agent licence under section 42 of the Act. For on behalf of Digital Signature of Applicant Digital Signature of Applicant \ . . ............ , r, Name of Applicant Title/Designation '? ll' V . ' ^..>1 Director/Partner or Sole Proprietor Director/Partner Place Date i t P i L # t M j vt j r } V I Y I V - Payment Options Credit Caid Debit Card Net Banking (i) On selecting "Credit Card” or "Debit Card", the applicant is asked for the following details: 8! 8.4 Details of thl! llxl!d deposit for renewal of license Name of the eank Addt-en F.o.r,,h..1mber Amount Helt! in Oepo1oil PercentilgE to hlitl.11 Olpital Maturity Date ... l'----- ---- -'------------'-------- - ----'-------------'-----------L--------- --------1 9. Declaration 111 THIS DECLARATION IS TO BE SIGNED BY TWO OF THE DIRECTORS, rNO OF THE PARTNERS OR THE SOLE PROPRIETOR AS THE CASE MAY BE. l I/We hereby apply for Ucence I/We have gone through the Insurance Regulatory and Development Authority (Insurance Brokers) Regulations, 2002 and am/are satisfll!d that I/ We am/ are eligible to apply for the insurance broker's licence. I/We state that I/We havl!! truthfully and fully answered the questions above and provided all the informatlcn which might reasonably be considered relevant for the purposes of my/our licence. I/We declare that the Information supplied in the application form Is complete and correct I/We undertake that I/WI! sh.all not allow or offer to allow, either directly or indirectly, as an inducement to any person, any rebatf" of the whole or part of the remuneration eamed by me/us during the licence period. I/We undertake to service the run-off business en the books at the time of cancellation or non renew.al of licence. I/We declare that I/we do not possess an lnsuranu .a1ent licence under section 42 of the AO:. For on bahalf of Digital Si~l"'ature ot Applicant I I Name of Applicant L Titll!/Designation Director/Partner or Sole Proprietor Dirl!ctor/Partner Place L I Date Payment Options Creditca,c Debit Card Net 8.anking (f} On sete-cting ·credit Card" or "Debit Card", the appllcant is asked for the fellowing details: ,....., 1 ""' ........ Card Number Expiration Cate wv |;/.#u.| Name on Debit Card (H) On selecting "Net Banking", the applicant is asked for the following details: Transfer funds from FORM B m f- K i ' & ? ? '***•■ GRANT OF LICENSE TO THE INSURANCE BROKERS 8? _______________ Important Instructions: See regulations 11 & 16 Please P rint or Type Characters Only in C jp ita l Letters LAi....b I c l o | e | M e l h | i J | K 1 1 1 M l N J,0 1 P J Q I R I S I T U 1 V 1 W I X 1 v i z ] 1. In exercise o f the powers conferred by sub-section (1) o f section 42D o f the Insurance Act, 1938 (4 o f 1938) the Authority hereby grants a licence to to act a s _______________ „ ___________________________________________________ broker (M ention details o f category) under that Act. 2. Licence Code for the insurance brol _ 3. This licence shall be valid from _____ 4. This licence is subject to the Act, Insurance Regulatory and Development Authority Act, 1999 (4 o f 1999) and Insurance Regulatory and Development Authority (Insurance Brokers) Regulations, 2002 and shall not be construed to be in com pliance with or in conform ity to any other Act, rules or regulations. By Order For and on behalf o f Insurance Regulatory and Development Authority Authorized Signatory Z______ _ Date | P | 6 | M ( M | Y 1 V 1 Y ( V | § Name Place 1 1 *• I THE GAZETTE OF INDIA : EXTRAORDINARY Card Number ' I {10 On selec1i11g "Net Banking'", the applicant k ask4:;d for the following d~tails: Transfrr funds from FORMS GRANT OF LICENSE TO THE INSURANCE BROKERS FORM j Important Instructions: See regulations 11 & 16 Please Print or T e Characters Only in C..pital Letters ;,!Ac' I C D E h G H I '.l ~ l M N ,0 P, Q R S T W Y 1111 I ■ I I UCfflJe No. I . In exercise of the powers conferred by sub-seclion (1) of section 42D of lhe Insurance Act, 1938 ( 4 of 1938) the Authority hereby grants a licence to _____________ to act as ____ ~ _ ______________ broker (Mention details of category) under that Act. 2. Licence Code for the insurance bro! ____________ _ 3. This licence shall be vahd from ______ to ____ _ 4. This licence is subject to the Act, Insurance Regulatory and Development Authority Act, 1999 (4 of 1999) and Insurance Regulatory and Development Authority (Insurance Brokers) Regulations, 2002 and shal l not be construed to be In compliance with or in conformity to any other Act, rules or regulations. By Order For and on behalfof Insurance Regulatory and Development Authority Authorized Sig,,atorv Date Name Place FORMC CERTIFICATE OF RENEWAL OF LICENCE ■ F O R M - I R D A - C . CERTIFICATE OF RENEWAL OF LICENCE Important Instructions: (Insurance Brokers) Regulations,2002 Please Print or Type Characters Only in Capital Letters____________________________ m ~T I c | D | el F | G 1 H I I [ J r K | - | I N [ 0 | P | Q I R I S.| T I U I V I W | X | V | Z License No. 1 The Licence of M/S _ Category _ _ Broker is hereby renewed under section 13 of insurance Regulatory and Development Authority (Insurance Brokers) Regulations, 2002 and Insurance Regulatory and Development Authority Act, 1999(4 of 1999) for the period__________ to _________ . 2 Issued at Hyderbad on day of _ , Two Thousand 3 This Licence is issued subject to the condition that the applicant shall comply with all provisions of the Insurance Act, 1938, iRDA Act, 1999, the Rules and Regulations made thereunder and the Guidelines,Circulars & Direction issued by the Authority from time to time. By Order For and on behalf of Insurance Regulatory and Development Authority Authorized Signatory ! i Date 1 D ] D | M j M 1 Y ) V~T Y Y Name Place FORMC CERTIFICATE OF RENEWAL OF LICENCE Important Instructions: (Insurance Brokers) Regulations,2002 FORM - IRDA- C t::EAJIFIC:ATE OF RENEWAL OF LICENCE Please Print or Type Characters Only in Capitol letters t A! a I c I o I E' I F I GI HI I I J Ii KI ~I M I NI o I PI o I RI s I TI u I v I w I x I v I z I License No. 1 The Licence of M/S _________________________ Category _________ Broker is hereby renewed under section 13 of Insurance Regulatory and Development Authority (Insurance Brokers) Regulations, 2002 and Insurance Regulatory and Develcpment Authority Act, 1999(4 of 1999) for the period ____ to ___ _ 2 Issued at Hyderbad on ________ day of _____ ~ Two Thousand _____ _ 3 Th is Licence is issued subject to the condition that the app licant shall comply with all provisions of the Insurance Act, 1938, IRDA Act, 1999, the Rules and Regulations made thereunder and the Guidelines,Circulars & Direction issued by the Authority from time to time. By Order For and on behalf of Insurance Regulatory and Development Authority Authorized Sign:story Date I D I D I M I M I ~ I Y f: V I ¥ I Name Place .j>. ....... , FORM D Audit Arrangements for an Insurarice Broker ■ ■ ■ ■ ■■ ■ ■ ■ . . . < . •' Filters and Param eters Year L... . . _ J Submission On Broker 1..................... 1 Submission Due Date # Name o f the Statutory Auditor Address o f the Statutory Auditor Nam e o f partner responsible for audit o f the broker Nam e o f internal Auditor (refer Regulation 27) Address o f Internal Auditor Qualifications (Pick from Dropdown general qualifications) Experience (N o O f Years) If an em ployee, to Particulars of whom does the changes, if any, internal auditor report? during the reporting period: Column Code a b c d e f g h ■ ■ ■ ■ ■ ■ M M H H 9 ■ ■ ■ ■ ■ ■ ■ ■ fi P # h m H p p W W H E H H ■ H U M ! ■ ■ 1y; m u B W f Pt MU HI . - - / j B fo r on t>ghatf of 0 «gss3 > S ig n a tu r e o f A p p h c a m ii..1."................................................................ ::.z z z z : N am es o f A p p lic a n t (./ jj' T it * c / O e 5 ig n a t » o n |7 . - - - . ~ - v >1 $ > g rt'm tu r* o f A p p is c a n t N a m e o f A p p lic a n t 1 ■ ■ : l T m e / D e s s tfn a tio n bus*5:............. ............. > Q s re c to r / P a r tn e r o r S o S e P r o p r ie t o r O ir e c c o r / P s rx n e r PS ace 1 X . :l D a t e I O | O | M .| V | V | 1 V | Y j THE GAZETTE OF INDIA : EXTRAORDINARY [P art III— S e c . 4] R1llMD Audit Arr-■-111■m■11ls for an Insurance Broker FIiters and Parameters Year Broker F.or on be-h.aU of fjt_ Title/De5i&nat1on r Name ot App l i cant Tttie/Oes1•na1:1on Duector/Pann,er or So loe Pr-oprie tor 01H!tc.:to,·/Pain:ner Date - -, Submission On Submission Due Date v I ., I & 1 \ FORM [ P a r t i c u l a r s o f p e r s o n s r e s p o n s i b l e f o r s o li c i t i n g a n d p r o c u r i n g o f i n s u r a n c e o r r e i n s u r a n c e b u s i n e s s Filters and Parameters Year 1 Submission On Broker l Submission Due Date Insurance Business / Name Address General qualification ( Pick From Drop Down) Insurance Qualifications (Pick from Drop Down) Experience (No Of Vears) Insurance Broker Exam - Year of Passing- Training Received (Oirect) Classes of Business handled (Pick From dropdown) Designation (Pick From Dropdown) Function Particulars of changes during the period a b c d e f S h i J Y ~ / . J. ___4 | 5 ~ 7 Z Z $ -£ # Name Address General qualification ( Pick From Orop Down) Insurance Qualifications (Pick from Orop Down) Experience (No Of Years) Insurance Broker Exam - Year of Passing Training Received (Composite) Classes of Business handled Designation (Pick From Drop Down) Functions Particulars of changes during the period ............ """ Column Code a b c d e f 8 h i ■ n i ■ H f l B l l M M I H f p w M H H W i ■ ■ ■ ■ ■ ■ H M ■ ■ ■ ■ M P P ■■M l p p p m p m p a S n B S r n w i f t p p p p i t i p a H ■ 1 ■ f f i i g : " v W S B B m * v K j h fo r on behatf o f S .gria a ii e o f A ppi-cer* N a m e o f A p p lica n t Title/Designation D ig a # i S ig n a tu re o f A p p n c# »it N a m e o f A p p lic a n t T itle / D »s ign a tio n IE DirecEor/ParXH-er o r SoSe P ro p rie to r D irector/Partn er $ ...____ ____ _ / FOIIME Particulars ol persons res Filters and Paramelen Vll!ar Broker • of insurance or reinsurance business Submission On 51.1bm lnl0n Oue Dilte General ln~ur.:1intt 1nsuranu- Brnlu•r P,:ut,r-ular, of Addreu qu11llf1cat1on Quaht1cal1ons hperlen(e E.w:am Ve;u of Tralnin.g Rrcf!1wt'd Clil u es of Bu\11'11'" , Designation chanr~ s durtnr. # Nilme Pa.s.i;u,,g (Cornpo-srte) handled funrt100\ thf' per,od I Pick Frnm Drop (Pick from Drop INo Of V,ean) (Pirk ~rom Drop ~ Down) Down) - - t '-11..,,,,, ( 1, I a b ---c-----------.-------.--------,-------.-------h------,--- Name o" AppHrant N:nme of Ap-p llcar,r I ... Title/Des ,s: n at1o n Orrll!!ctor/Par'\.t~r or !.olie Pro;:,r •eJ.or O lr@'ctor/Part.n~, ,...., ~ i I - I fOMlf Particulars of FIiters and Parameters Ytw Btoke< , lstered and branch offices . )&W.-, courtt/llotAf! Qu•rttr S..bmlulon Due D111 Submrnlon On . -~- - .. ,S::.:SP:- I ~ ::j @ C) ~ m ~ [Tl 0 ..,, z 0 > II ·· tTl >< ~ 0 :;Q 0 z > ~ ~ ~ == ..,.. Pl ~ [*TFT III— ' 4 ] { : 3TOT%IKui 71 For mt fretigtf of Digixvtl Signature o^AppSi scant N a m e o f A p p lic a n t T J tS e / D e s 3 g n a t*o n .fc ^ -j,IE 5 g j HB! N a m e o f A p p lic a n t ■ 1 T t t ie / D e s ig n a t io n (. 1 D ir e c t o r / P a r t n e r o r S o i e P r o p r ie t o r D ir e c to r / P a r tn e r P la c e N . 1*.. ...... 1 1 O 1 D I M l M 1 V I V I V I V I FORM a S t a n d in g a r r a n g e m e n t s w i t h o t h e r i n s u r a n c e b r o k e rs o r s e r v i c e p r o v i d e r s ________________ Filters and Parameters Year |_________________________________________ _____________ | Submission On Broker 1 | Submission Due Date « ■ Name Address Particulars of arrangement *Any agreement entered into with others? Yes/No Whether service provider is/are from group companies - Yes/No? Basis of Remuneration (Please select from the dropdown) Amount paid during the latest financial year 1 — .......— . 2 ___ 3____ ____ 4 5 ■ -..... . , — — — ............. - ...........- — ----------- ■ ....... - - ..............— ■ . --------------- . . . — ..........— --------- -------- - * If ANS to column 'c' is Yf.5, please attach copy of agreement entered with others £or on; Oehatt of___________________ i grtsrure o f *.pp -cant N a m e o f A p p lica n t 1' .. :.7~3 TitS e/ D e sign a tio n emmm D irector ./Partner or Sose P ro p rieto r D irector/Partn er PSace ['IWT Ill-~ 4] 71 For 011' b-1'!-hal·f of N.!lme or App 1tcant t i 1 SI .. tura ,.... ·., I WIM-¥4- Name ot'Apptlcant Oirf!ctor/P-ai rtner or 5o!e Propdecor Ol rector/Part.n er 0 , .. [Jij):i I MU M 1 v I ~ r I ,. I IIDRM l!i Standing arrangements with other Insurance brnli:ers or service provldeH --~---------------------------~ Filters and Parameters Yl!ar Brokl!r Submission On Submission Due Date Whether service Basis of •Any agrHment p10vider is/are Remuneration Amount patd during the # Name Addtess Partklllar~ of entered Into with frm11 group (Please select latest finandal year . arrangement oth , -'N . fram the e,s Y~ o rnmpu11es - d d J Yes/No) rop own - ~ - - - -- ------ ,..,,~,, .. ,"<), ~ t, r d • f ~ If ANS tn column '<' is Vl.5, 11/f!a.w. altm:h COIIY of agrel'!me11t eme,'i'd wirh other1 . ' .. ,. Premium On Reinsurance 8roking In Respect Of That Client's Business Miscellaneous Marine Miscellaneous Column Code Total Of All Clients Filters and Parameters Year Broker Name Of The Client Premium On Direct Insurance Booked for the Client Address F.D Number Amount Held in Deposit FD End date 72 THE GAZETTE OF INDIA : EXTRAORDINARY [Part III— S e c . 4] FORM H Spread Of Business During The Year Ending Filters and Parameters Year I '' ' 1 Submission On Broker .1... ....." " " 1 ............................ _.............. Submission Due Date Yes/No Yes/No Yes/No Yes/No Yes/No D ir e c to r/ P a r tn e r o-r S o ie P r o p r ie t o r D ir e c to r/ P a r tn e r P*ace \ ,Ti t ijX-.Vl f c l ' V & rlaiiigsi D - ^ s ta s S ’. & n a t u r e o f A p p n a r i t H U N a m e o f A p p is c a n t T itS e/ D essgn a tison Note: 1 The top 5 clients (as defined in regulation20) should be listed. 2 Where the Broker did not handle 100% o f the business, the premiums should be shown for this broker's share. Where the premium is payable in installments, the total premium accounted during the reporting period should be shown. Submission On Submission Due Date Important ** This information has to be provided for each case in case brokers has kept fixed deposites in more than one bank FORM I F ix e d D e p o s i t D e ta i ls Note: 1. Confirmation that Lien is marked in favour of IRDA 2. Letter obtained from bank stating that the principal amount shall not be released without permission of authority 3. Whether FD is kept in scheduled bank? 4. Whether license period covered, if not then undertaking given to maintain FD throughout the license period? 5. Whether covered by regulation 2 (1) (J)(V)? Do You want to add another record for FD details? Yes / No If Yes populate same screen , 72 THE GAZETTE OF INDIA EXTRAORDINARY [PART III- SEC. 4] FORMH Spread Of Business During The Year Ending ------ --="----------------------------------------' Filters and Parameters Year Broker Total Of All Clients Note: L___ ] 1 The top 5 clients (as defined In re1ulation20) should be listed. 2 Where the Broker did not hilnd1e 100% of the business, the premiums should be shown for this broker's share . Where the premium is payable in installments, the total premium accounted during the reporting period should be shown. Name of App h cant: Tirle/Des•,rnat10n E:11reccor/Pertner o.r Sole Frop rie:tor Directol'"/P&rt:n@I'" Piece IRMu, Fi,od Dopo,lt Details Fllt1r1 ilnd Pilrameters Yitar Broker Important St1bJT1lsslon On Submission Due Date •• This Information has to be provided for each CHe in tue brokers has kept theed depositH In more than on• bank Addrl'\1 F.0 Ncmber J ' __ , j l Nott!: 1. Confirmation that Lil!!n It marked in favour of lROA 1. letter obtainl!d from bank statin1 that the prlnclpal amount shall not bl! rl!lused without pumission of authority l, Wht!thu FO Is k•pt in schedull!d bank7 4. Wh•thl!!f licl!!nse period covl!!rl!d, If not then undertakin11lv•n to mt11intaln FO throu1hout the tlcens@ p•riod? 5. Wht!thu cavl!red by rqulation 2 (ll IJ](V)? Do You wan, to ;idd anothu record for FO details? If Va~ pdpulate Hml! scr"l!!n Yes/ No FD End d.;te Submission On Submission Due Date _J [*fFT III— 4] < ‘HKcl : STOT^TR10! 73 --- # Name o f the Bank JPPWPBJPJNB FD End date Column Code ..... e ..... L.u 1. Confirmation that Lien is marked in favour of IRDA 2. Letter obtained from bank stating that the principal amount shall not be released without permission of authority 3. Whether FD is kept in scheduled bank? 4. Whether license period covered, if not then undertaking given to maintain FD throughout the license period? 5. Whether covered by regulation 2 (1) (J)(V)? Yes/No Yes/No Yes/No , D-£?TS:> N a m e o f A p p i icanr T itS e/ D esign a tio n i.... .......: : - - - - - J S'fciftTwie c'Aop-i?9M . N a m e o f A p p itc a n : T itie / O e s ig n a ric n [."^7 )• A ' r. D i.-ecter/Partner o f -Soie P ro p rie to r 05 recto r/ P a rm er Race r«5 t&zm „1 D a te I i H 1 y~l FORM J Insurance Bank Accounts of Insurance Brokers Filters and Parameters Year j | SubmissionOn SubmissionOn Broker f~ | Submission Due Date Submission Due Date O r ? i c » i S i- g n a tu -re o f A p p l *ca n i: V ' : ® ; w ® -v ;• -jr:;■• N a m e o f A p p l i c a n t T « U e / O e s iig n a t s o n Type of Account „ , Bank A/C No. F or Name and address of the Bank Column Code Purpose of Account (Yes/No) d Whether Reg 23(2} (C ) complied with Balance in account as at end of reporting period D i# it a ■ S : g r, a t u r e O f A p 0 i 1 1 '■ '. i s ' .1 N a m e o f A p p l i c a n t r ....:...... ................. ......................i T s t i e / D e s ’. g n a t i o n h " t - - . ' . :i D ir e c t o r / P a r t n e r o r S o l e p ;*a ce D a t e P r o p r i e t c r Qs r a c t o r / P a r t n e r i - - s . i . m : < t m i ;, | o 1 m i M i y I V 1 . | v ] [ 'IWT lll- ~ 4] m=rT!-ffiUT Not• 1. Confirmation that Lien is markE!d in favour of IRDA 2. Lettll'lr obtainl!!d from bank stating that the principal amount shall not be released without permission of authority 3. W hether FD is kept ln schE!duled bank? 4. W hether license period covered, If not thl!!n und l!!rlaking given to maintain FD throuli:hout the licl!!nse puiod7 S. Whether cOVll'!rl!!d by regulati on 2 (1) (Jl(VJ1 for~h<" •• r Of Nam @ o1' Appncan ~ . I t otpJt,\ l i.ttJl ilJ.J....iJ FDRMJ Insurance Bank Accounts of Insurance Brokers Filters and Parameters Year Broker Submission On Submission Due Date Submission On Submission Due Date Purpose of Whether Reg Balance in account as at end of Type of Account Account 23(2] I C I reporting period • Bank A/C No. complied with Name and address of the Bank ___ (Yes/No) I 2 3 • 5 6 7 Column Cod-e .> b c d f! - -1--------1---- --·----- - ----1--------'-- ·------- -- ------- For Of'I be-half of Na m e o'I" Ap p h ca nt Oir~ctor/ Part:ner or So l e P roprietor D.rector/Part.n ll!!-r Dat e 73 74 THE GAZETTE OF INDIA : EXTRAORDINARY [P art III—Sec. 4] FORM K P r o f e s s i o n a l I n d e m n i t y I n s u r a n c e In F o r c e A s A t - Filters and Parameters Year Broker ' Submission On Submission Due Date FORM L C l a i m s D a t a f o r I n s u r a n c e B r o k e r s Period of insurance: (From Date) Period of Insurance: (To Date) Sums Insured: Per Event Column Code Deductible: Premium for the cover Whether requirements forthe / Regulation 24,sub- regulation (4) and (5) are complied with ? (Yes/No) Please State The Relevant Percentages Sums insured: in Aggregate for the Policy Period (AOY) Claims Movement i i n i ........iSmrnmS Claim Amount ___ i Claims pending at the beginning of the quarter . 2 ~ New Claims registered during the quarter _ ... . .... ^ . . Claims settled/closed during the quarter L l i . J Claims rejected during the quarter 5 1Claims pending at the end of the quarter \ =l+2-3-4 .......- w - 5'4 Name of Insurer providing PI Cover Policy No/Endorsement No. Basis o f Indemnity (On claims made basis or on loss occurring basis) Name of client concerned Nature of event likely to give rise to a claim Brief description of basis of claim Submission On Submission Due Date / m w, Please state every event that has come to the company's notice where the company may become liable to pay damages or compensation to clients, whether covered by the professional indemnity policy or not, giving the following information Filters and Parameters Year Broker Quarter Claims Details Date of period of occurrence. intimated or estimated. amount of daim Whether covered by professional indemihty policy: Amount provided by the broker in its books for the claim Present status of claim. D irecto r/ P a rtn er a S<o«e P ro p rie to r C P ia c e 74 THE GAZETTE OF INDIA EXTRAORDINARY FORM K Professional Indemnity Insurance In Force As At FIiters and Parameters Year Broker Submission On Submission Due Date - ---- --- - - - - -,- - ---- - -- - ---- - - - - 0 , . ,-- FORML Clalms Data for Insurance Brokers FIiters and Parameters Year Broker Quarter Claims Details Submission On Submission Due Date I --.:.~-~=-i- ... ~~~~~- ------·- -· - - --r -------t- - ··-- -·--·- ·---- - Claims Movem~nt ,1.1 • _j ., "'" 1•11~ _ ' -.t • lair Claim Amount liCI, ..,, od. ,. h .. _l:,__ New Claims r is1ered durir,R, the quarter t 3 Claims settted/dn~1 the quarter ·---~~--=~ r·- 4 - CJal~s rejecte~~- - _ S CJaims endln at the end of the uarter •1+2-3---4 [PART III-SEC. 4] [*?FT III— 4] 75 Aging o f pending claims ___ __ Total « Pending claims aging buckets * No. pf Claims Claim Amount 1 [ Column Code a b _1 __ Pending for upto 1 month Pending for greater than 1 month and upto 3 months ~~ 3 Pendingfor greater than 3 months and upto 6 months 4 Pending for greater than 6 months and upto 12 months 5 Pending for more than 1 year 3 Total Pending : * =t+2*3*4+5 * Reckoned from date of first intimation Aging of settled claims Settled claims aging buckets No. of Claims Claim Amount 1 Settled for upto 1 month: _2_2_ Settled for greater than 1 month and upto 3 months ___3_~ Settled for greater than 3 months and upto 6 months ..........___ 4 ! Settled for greater than 6 months and upto 12 months 5 Settled for more than 1 years Total Settled j ~=t+2+3+4+5. j■ =*+2+3+4*5 ** Reckoned from the date of receipt of last requirement M ajor Claims Pending - Above 1 Crore For on b eh a lf o f______________________________________________ O 5 # j s n » r u < - e o< Applicant _______ :__ !__m ____: N a m e o f A o p * Scant T itJe/D esign a rS ^n ">x '"" ’ 0>£:-t.Sf:. Signature of 4ppi'c»nt r; ....... . ^ .y-^ryTj N a m e o f A p p lic a n t — .... F ~ \ Tijie/Cesignstsop t I Difeceor/Partner o rS e fe Proprietor Director/Partner Pface o.te r?c8*am i M 8 W 1 v t Y 83B FORM M Reinsurance balances outstanding as at— (End o f Financial Year - 31st March) Filters and Parameters Year _______ J Submission On Broker Submission Due Date Description Amount outstanding for a period of 1 0-3 Months 3-6 Months 6-12 Months Over 12 Months Total Column Code a b c d e i J Due to ceding companies 2 H Due to reinsurers 3 Due from ceding companies 4 Due from Reinsurers '•............ Signature of AppSscwnt [ ~wr III-~ 4 J Aging of pending c/olms _ Total ff I Pe,ndlng clalms asl~g buc~e1s_: _ _ No ol Claims l Claim Amount_ Column Code ;ii b J Pending for grHterthan 1 month and upto 3 months ·- ~ --m• Pending for upto 1 month 3 Pending for greater than 3 months and upto 6 months -~ 4 Pending for 1reater thin 6 mooths and upto 12 months 5 Pendina for more thal;;-1 yea-;- llot1I Pt!nidlr:11 • Reckoned from date- of first 1n11mar1on Aging of settled c/olms Settled for gruter than 3 months and upt o 6 months Settled for _lVeater than 6 months iilnd upto 12 mo---;;i"hs "s;nled f~~ ;;,,ore than 1 vears ====cc.__- -t----- Tot.al:!lettla •• Reckoned from the, 1h1te of receipt of last requirement Major Claims Pending 4 Abo.,e 1 Crore Name or A.pp 11can, .. ,,. .... ~eme of Appl 1c.an1. LF§Xfi= ;•~-_m_1...,,:jj..,s .... • ~ ~~'·· :.J 'T, tl e/ D@!i:. ' Cnllt>O{l C: P! Bc:e FORMM Reinsurance balances outstanding as at--- (End of Financial Year - 31st March) Filters and Parameters Year Broker Submission On Submission Due Date n _ Description __ _ _ _ Amount outstanding for a period of _ _ ____ _ __ i= ___ ___ 0-3 Months 3-6 Months 6-12 Months a~er 12 Months Total 1 2 1 4 Due to ceding companies Due to reinsurers -- - - Oue~om ce_~~£_companies Due from Reinsurers For o n au of Namie o -'PP ,cant Column Code a b c d e 75 76 THE GAZETTE OF INDIA : EXTRAORDINARY [P art III— S ec. 4] T it le /D e s sg n ati o n D j - t c : 5 > g n atjju r s o f A p p c a n : |-----—------------ ------------ :---- ----— Na m e o f A p p I icant T tt i e / D e 5 ig n a t s on D ire c to r/P a rtn e r o r Sose P ro p rie to r D ire c to r/P a rtn e r P? ace 1 ' - D a te I P I O I P.-I I M I Y i j Y I Y : li: Y~ FORM N S e c u r it y s c r e e n i n g p r o c e e d i n g s f o r r e i n s u r a n c e b r o k i n g Filters and Parameters Year Submission On Submission Due Date . Please state the security screening procedures adopted in the brokers office and the person responsible to approve the securities to be used by the broker, and in particular, stating Whether the broker obtains and reviews the annual accounts of reinsurers used by it, (Yes/N o) • . '* (// answered 'Yes' for previous column) Who within the organization is responsible for this function? ' Procedure followed by the broker to keep abreast of developments in the international markets: BHHNMMNi c 1 1 ... : 2 • "1 3_ 4 L............. fo r on t>ehaJf o f C- s -t»* Signature of App': v.; CZZZZ3EZZ~EZ!E: N a m e o f A,pp3icant T i cs e / O e s Sg n a tio n D «:* s ? S ;jn 9 tu fft o ' A p p 76 THE GAZETTE OF INDIA EXTRAORDINARY [PART III-SEC. 4) 1"itle/Desi,enatlon • ,..I _.c __ _.c..; _____ I D t t..::zi 5 i'f"'ISt.ure of 4.pp ::an;: r-.Jani~ cf App llc:ant Ttt.te/De~tenat.cn Dir~ct.or/Partner or .So1 e P·rop r•etor O~rect:or/Partner DI D I MI M I y y y l...!J FORMN Security screenln1 proceedings for reinsu=r:..:a::..:n::..:c:..:e:..=b::..:ro=-.:..: ki::::.n__,,g,__ ___ _________ __________ _j F"llters and Parameters Vear ~or on betu111 or T11!:1e/011!!!5:anation Submission On Submission Due Date h d * £ //1 6 FORMO C a p i ta l S t r u c t u r e a n d s h a r e h o l d e r s d e t a ils f o r a n I n s u r a n c e b r o k e r Filters and Parameters Year Submission Due Date Broker Submission On C a p ita l S t r u c t u r e ft ] Particulars Amount Percentage Column Code a b _1 1Authorized capital __2_ Issue Capital 3 Paid Up Capital 4 Free reserve excluding re-valuation reserve ___ 5___ * Net worth of partners r ~ | * Drawing to partners / owners * Loans to partners / owners FDI D e ta ils ft Shareholder Name Total Equity Share Capital % Holding Column a b c 1 Indian 2 Foreign Direct Indirect S h a r e h o l d e r D e ta ils (Provide list of All shareholders holding 5% and above of applicant directly or along with associates-applicable only to limited companies) ft Category of Shareholder (Foreign Direct/Foreign Indirect / Indian) Name of the shareholder Address of the shareholder Business or Profession Shareholders Unique ID (Indian: PAN No) (Foreign: Tax ID) Shareholding as at end Shareholding as at of reporting period end of reporting (Number) period (Amount) Date of changes in shareholding during the period Particulars of changes in shareholding during the period Loans and Advances to the Broker Firm Other Investments in the Broker Firm Column Code a b t d e f h j ■ m ■■■& ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ H H i J M A t t U H H J V m m ia d W H fiS ii sttHflpiifepBHilifiMEAB B H i i p p p a a i f i v A n p ■ H i p p ■f e n m i ■ n i n » M i p H B o B tmrnmm mm iwflMi i i B H H b mmtmm M H i i f e i S K In itial S u b s c r i b e r s o f M o A « Name of the Subscriber Address of the subscriber Business or Profession Shareholders Unique ID (Indian: PAN No) (Foreign: Ta* ID) Shareholding as at end Shareholding as at end of reporting period of reporting period (Number) (Amount) Date of changes in shareholding during the period Particulars of changes in shareholding during the period Loans and Advances to the Broker Firm Other Investments in the Broker Firm Column Code o b c d e / g h .........." ....- ■t V ■ ■ ■ ■ ■ m U H I I H im fc tiriH H fi& fitffi t t g H B I U s ■ ■ n H j i g t f f m M K H i ■■■■t a B V s M l i n H H f l K I R E I M i H i ■ H I I B t t n B A d B U B n A H M M W HHBiMfiJPtttE! j^ m h m b i b M B H H H ■ H H H H M H M B H M I ■ * y v > - - ’ . ■ ■ m ■ H M H B e h M H H I ■1 ■B H U H M m ■I t f l l ^ 1 ■H H H B I l i H k H W M B H H fe m A N M B H ■i B M H U i l m I H W H R H R W H B H y i H imucmBHiTC ■1 m t t & B H n n mm HWWHIISK o U A H O I H M h ■H H M M D H H l M B H H m n m [■RFF III—7^5 4] *TRcT - I a § FORMO Capital Structure and shareholders details for an Insurance broker Flltus and Parameters _ 3_ 4 5 Issue Capital Paid Up Capital Vear Broker Free re~erve exdudina re-valuation rl!serve • Nel;,orth of partners - ~ nltopl~;;-,~ --- -~~ artners/owner§ ----- --1--- ---- - - ----·-I------ # 1 ~t,a~hnlder Name % HoJd1ng I I Total Equity Share I ~ _ L:lp1t.1l • Column ♦ a b c lndian Indirect'" Submission Due Datl! Submission On Shareholder Details . Shareholdlng a~ i:it e,id Sharehold1ne as at Datr- of tha"I"' Particula,.., t'.lt ..,._,.,choldeM Unique ,ti.angel. ,n # (ate«or'I cf Shareholder frore1gn Direct/Forel1n :::h~I~:; A!d::~o~~=e ~:~:::0; 10 af re~:~~':e~;riod ;;~_: ;::::~ d•:n~~;~:.,~:~~ sh.1,Phold1n1dunne loan\and AdvancP, 1:, Olh~r lnvc,lments ,n lnd,,ect / Indian) !Indian PAN No) the penod the Broker r,rm the 8rckt-r fnm IFore,gn TAJt ID) • Column Cade -: ---.------b------,-------.-------.------1 -----,-----h--- , / a 00 c n J «A d d R ow s» Associate Company Wise t) Name of the associate company Address of the associate company Business or Profession Shareholders Unique ID {Indian: PAN No) Shareholding as at end Shareholding as at end of reporting period of reporting period (Number) (Amount) Date of changes in shareholding during the period Particulars of changes In shareholding during the period Regulatory body (Foreign: Tax ID) Column Code a .... b c d e f g h Source/Calculation | J M M l i s s m s i H F V l p u m i m Q P H B H H I ^■*1W g«ftSaaiB a|j n i M f l H Nta H n ■b l i l H I B f l H l m ■m m m m m I S l m i ■P H B O U H B I H H H h H i l H Q H B E G M ilH R m m ■ ■ H q i i M M n I M A . H U K ■1 ■ I H P H P H H I I H I V, m m i S i B i i i i H n M H r i H I * Applicable to only partnership or proprietary concerns f-or on befialt of Signature of *.pp '.sr N a m e c-f A p p Jlc»n t 7<t!e/D eSign8t>on O: ? ; 3 > £ n « V u r e o f ftpp N a m e o f A p p lic a n t 32ZZ T t i e i 'D e s i jn a t i o n t l’ ~ j - . i- y > D irector/Partn er o-r So*e P ro p rieto r D ireccoi/PB rtner Pi s e e I *'*: ' **"} , t; | e> j m I m j v } y :.1 y I y I FORM P Board of Directors and management details . ... —4 Filters and Parameters Year j Submission On Broker f Submission Due Date v ' Details of the Board of Director/ Principal Officer ..... THE GAZETTE OF INDIA : EXTRAORDINARY [ P a r t III— S e c . 4] -· • Applicobl~ to only partn~rship or propri~tary conc~ms Na,.,,e of' AppUcant N~~e cf A.ppHcant ... ,,;;, 1 u .I D f M I M 1 "' I \'! 3 ·Y I v I FCJRMP Boart.l of Directors and management details Filters and Parameters Year Broker Submission On Submission Due Date Details of the Board of Director/ Principal Olll11r -l :r: tT1 C) ~ tT1 ~ 0 'TJ z 0 ► ff Name of the person PAN No. Address (Street, House) City District State Pincode Profession Appointment/ Cessation Date Designation if holding position changes during the period since the last report Details of Directorship in other entities (If any) Column Code a b c d e f g h i j k S W M MMtHkflHtil tfutttttl H li ■H H W ra i ■ ffH B t .- HWM UUUH n S ■ v r B a rm m W HHi r m E ■ ■: B iH h U H da ration: am not sufferring from any of the disqualifications specified under sub-section (5) of section 42D of the Insurance Act 1938. am not holding Agency/Surveyor/TPA license do not hold directorship/employment in/or represent any other Insurance related entity I have filed FORM - 32 with ROC (‘ only applicable for directors) Attach scanned copy of affidavit.» Yes/No Yes/No Yes/No Yes/No Persons In Charge of Management 1 —--- if Name of the person Address (Street, House) City District State Pincode Designation Shareholders Unique ID (Indian : PAN No) (Foreign: Tax ID) Nature of Functions Qualifications Experience including Insurance experience Nature of training received ■ Duration of training received Column Code a b C d e f g h 1 j k 1 K M rik n H i ■ H ■H H DH i m s ^ K M ■ 1 0 1 H H M H H M n ) ■■■■■■ ■ . 5 3 B H v. - . B IB ' ■H m m m igg - BmH IB B B IHUHBIl arfifii H M B m HHVMH B P p mtB B p n ■HHHUHW B 1B Mf BIH ■ W S i For o n b e h a lf o l Dsgtcaf. S ig n a tu re o f A p p ik a n t j N a m e o f A p p lic a n t i , .zi Tit? e /D e s ig n a tio n i... * i DiigsTa? S ig n a tu re o f A p p lic a n t i N a m e o f A p p lic a n t T itle /D e s ig n a tio n i . ....... : ■ 1 \ T ' K ' t 1 D ir e c to r /P a r tn e r o r S o le P ro p rie to r D ire c to r/P a rtn e r P iace D a te [*Pf III— TsTJS 4] 'RTCcT TTSrTSr • - - Appo•ntment/ 0e'51gnat1on •f holding changes during the N.1ine of the prri;on PAN No Addre5s I Street, Profession Cessat,on Date position petiod since the last Detallc; of # Housel City D1stnct State P1ncode report Directorship ,n other entities {If any) l~r,,~~c:x1c~ b . c d e f g h , J le -- r -- -_-1 7 clar1tlon: am not sufferrin1 from any of the disqu1llflc1tlons specified under sub•sectlon (5) of section 42D of the Insurance Act 1938. am not holding AJ,ency/Surveyor/TPA llcense do not hold directorship/employment In/or represent any other Insurance related entity I hov• filed FORM· 32 with ROC (*only 1ppllceble for directors) Attach scanned copy of affidavit,>> Vas/No Yes/ No Yes/No Yes/No Persan!I 11'1 Char11 of M1i.11■ment N."lme of the person \h;u(lholders Unlqur. C.perience Naturf' of training 11 Addrpc-,\ (~trrf't, C ,ty 01c;t1,ct State Plncodc Desiimu,on ID Nature of Functions Quallftcat1ons including Insurance received Duration of Houst:') llnd1an PAI\J No) training received (Foreign. Tax IOI experrence C::;,um,,Cooi• a b ---c---,---d--- e ----,- g h I J ____ k _______ l __ _ J For on beh-a If o f Name of Appt lcant Name of AppOcant Titfe}De·s.ienat·\on r Oireaor/Partner or So l e Propri etor Director/Partner Pta-ce Date IO ID I T ,--, 1 .j::. '-J Filters and Parameters Year Submission Due Date Broker Submission On Income Data • Description (Rs. In Thousands) Amount L Direct Insurance remuneration 2 ........ 3..... Reinsurance remuneration Advisory fees 4 5 Insurance consultancy Investment Income 6 Others Total Sum (rowsj Invpttmpnt nnta (InvoctmAnf in prmmc) ................. 1 i--------------------------------------------------------------------- :: -------- *-------- . ~ ....... .________________________________________________i # Description (Rs. In Thousands) Current year (As per selection) u i Column Code j a ..V 1 2 Group Companies Equity ; ....... . ..- j, 3 4 Debt Loans/ Advances given directly or indirectly to group companies .......... - •: i r ....- ....................i 5 Others Total sum (rows) ■ Note Is there any other information relevant to the financial data of broking firm over an above captured in above forms to be declared explicitely ? Please attach relevant documents as annexures and enclosures Action If Yes, system should enable user to attach relevant documents _ ^ D o c u m e n t C h e c k lis t Yes /No Document Checklist Document Required Uploaded Document Name V |DocName1 Attach xxx. doc Remove For on t»ehalf of * xxx.jpg Remove D i g 't r a * T > '$ n * a?u « e o f A p p - i s c a n t iL. Nam e of Applicant: T it t e /D e s * g r> a t *© n THE GAZETTE OF INDIA : EXTRAORDINARY [ P a r t III— Sec. 4 ] FormQ Financial data for Insurance Brokers Filters and Parameters Year Broker Income Data # Description (Rs. In Thousa~ ~ 4 5 6 Direct Insurance remuneration Reinsurance remuneration Advisory fees Insurance consultancy Investment Income Others ~ .... .uu.,.. a "'"'' sum (rows} l11•••••LData fluu ■-.allllll ;:"11,r•I ~ emarks frOll'I # Description (Rs, In T tat~tory;'. • 1 f'An • . b 4 5 Note Group Companies ~Quitv Debt Loans/ Advances given ~re~tly or indirectly to group companies Others Total sum (rows} Is there any other information relevant to the financial data of broking firm over an above captured in above forms to be declared explicitely? Please attach relevant documents as annexures and enclosures Action If Yes, system should enable user to attach relevant documents Document Checklist Document Checklist Submission Due Date Submission On Document Required Uploaded Document Name J □ocName1 , ... . 4 • • 4_ .... For on behalf of Name a1 App li:c:anr Tlt•e/Des ; enar.1on . , ~cum: I xxx.doc XXX.JP9 • Yes /No Remove Remove --l ;:r: m Cl ~ tTl ~ tTl 0 'TJ z 0 > tTl >< --l -~ 0 § ~ ~ ...... f VJ Pl .£: S i j n e t U f O o f A p p i i a n : I • - ■ - -■ ~ • 1 [ ’TFT III— 4] TRcT ^T IF T O : O T T O 81 N a m e o f A p p H c a n t T « t s e / Q e s * g n a t * o n D ir e c t o r / P a r t n e r o r S o i e P r o p r i e t o r D ir e c t o r / P a r t n e r P J a c e Date 1-0 To \ M I'M 1 f f yT v T v l FORM R DUPLICATE LICENSE FORM - 1RDA - R DUPLICATE LICENSE Important Instructions: See regulations 11 & 16 Please Print or Type Characters Only in Caoital Letters 1 A I B 1 e l D I t J F 1 <3 t H i 1 ? J K | t j m I n t o ] p 1 n 1 r 1 ■ s 1 j | u t v. | w | X | Y u 1 1. In exercise o f the powers conferred by sub-section (1) o f section 42D o f the Insurance Act, 1938 (4 o f 1938) the Authority hereby grants a licence to under that Act. 2. Licence Code for the insurance broker is 3. This licence shall be valid from _____________ (Mention details of category) 4 This licence is subject to the Act, Insurance Regulatory and Development Authority Act, 1999 (4 o f 1999) and Insurance Regulatory and Development Authority (Insurance Brokers) Regulations, 2002 and shall not be construed to be in compliance with or in conformity to any other Act, rules or regulations. By Order For and on behalf o f Insurance Regulatory and Development Authority Authorized .Signatory r ~’~~ ~ ~ ~ ~ ^Name 5 (1 6 1 1 /2 — • 81 r""· f'-J arne of App !ic a,,r Di r ector)Part:ner o-r Sole Propr!ei:o·r Clireccor/Pertner P l a·ce FORMR DUPLICATE LICENSE Important Instructions: See regulations 11 & 16 Llunse No. l!~Rlll - llilH - ll DDPEICA'l'E tlCEIIISE Plea~e Print or T e Characters Only in Car,ital Letters ~----' In exercise of the powers conferred by sub-section (1) of section 42D of the Insurance Act. 1938 (4 of 1938) the Authority hereby grants a licence to ~~"----------------- tr (Mention details of category) under that Act. Licence Code for the insurance broker is This licence shall be valid from _____ to ___ _ This licence is subject to the Act, Insurance Regulatory and Development Authority Act, 1999 (4 of 1999) and Insurance Regulatory and Development Authority (insurance Brokers) Regulations. 2002 and shall not be construed to be in compliance with or in conformity to any other Act, rules or regtJlations. By Order For and on behalf of Insurn.nce Regulatory and Development Authority A-Jthor1r':'d Signatory D•a QD' MM'f\'\'¥ iName 82 THE GAZETTE OF INDIA : EXTRAORDINARY [P art III—S ec. 4] APPLICATION FOR DUPLICATE LICENSE important Instructions: APPLICATION FOR DUPLICATE LICENCE _____ _ __ ........t i l l Please Print or Type Characters Only in Capital Letters 1 A .{- B-frC 1 D | l l j 1 G 1 H 1 1 1 J.-l K j- I 1 M[ N \ o j P f a]?8,j j j. T | U 1 V 1 W 1 X I Y-j 1 .) 1.1 regret to inform you that my/ our licence no._______ expiry date_______ has been 1. lost {Affidavit giving details of loss and return'license on finding the same} 2. destroyed (Affidavit giving details of Joss and return license on finding the same) 3. mutilated (Return original license) by the following cii circumstances 2. Fee Payment A non-refundable fee of Rs. 1,000 will need to be paid to IRDA via the e-payment options displayed to applicant on submitting the online application form. 3. Declaration I hereby apply for the duplicate license under regulation 16. 1/ W e , therefore request the Authority to kindly issue a duplicate licence in light of the circumstances explained above. I,......*......................solemnly declare and confirm that the particulars given above are true to the best of my knowledge and belief. Date [ 0 j D | M [ M I Y | Y | . Y I >-1 Name Place I - | Date 1 P J D I M I M | Y | Name Place Payment Options Credit Card Debit Card Net Banking (i) On selecting "Credit Card“ or "Debit Card”, the applicant is asked for the following details: Card Number ..... ^ ' -' j Expiration Date [Year „ | cw [ . Name on Debit Card [I* v ' I:' • 1 V M i H i i m m m (ii) On selecting “Net Banking", the applicant is asked for the following details: 82 THE GAZETTE OF INDIA EXTRAOR:bINARY APPLICATION FOR DUPLICATE LICENSE Applllltlon D14 ... Lklenla Important Instructions: APPLICATION FOR DUPLICATE LICENCE Please Print or Tie_e Characters Only in Capital Letters 1. I regret to inform you that my/ our licence no. __ expiry date __ has been by the following circumstances 2. Fee Payment l. lost 2. dertroyed 3. mutilated (Affidavit giving details of loss anci return-license on finding the same) (Affidavit giving details of los5 and return license on finding the same) (Return origlnal license) A non-refundable fl!!e of Rs. 1,000 will need to be paid to IRDA via thee-payment option5 displayed to applicant on submitting the online application form. 3. Declaration I hereby apply for the duplicate license under regulation 16. [PART III-SEC. 4) I/ We , therefore request the Authority to kindly Issue a duplicate licence in li1ht of the circumstances explained above. ; I,·-···~---- solemnly declare and OJnfirm that the particulars 1iven above are true to the best of my knowledge and belief. Name Place Name Place Paym~!lt Option5 C.1editCard Ne!t Banling (I) On selecting "Credit Card" or "Debit CardM, the applicant is asked for the following details: Card Numbe1 Expiration Oaite cw Name on Debit Card (ii) On selecting "Net Bankinrt, the applicant is a1ked for the following details: T '" tunas from o,,. I p;J O I M I M I Y J ' I t f FORMS Business Data for Insurance Brokers : v - ; 0 M BiSSaSSSS Filters and Parameters Year Submission On Submission Out Date [inturar W w ftwlnW Fliures - Non-Ufe _ Name of livsuren Mar Column Code a Sourre/Calrutation No. of Pofeties no HuB b Premium Marine Cargo t d No. of Policies Premium a f No. of Policies Premium fl No. of Policies h Premium Health No. ofPoBcies Premium Engineerlnfl Uabilit> k 1 rrf N o o f Potkies Premium No. of Policies Premium No of Policies hmnwmm 1 I : 4 1 1 1 1 »s5 »*« rmrtm S B »t»-~ Name of Insurers Column Code source /calculation fio of Policies Me t> Premium t No. of Policies Health d Premium Pension e f No. of Policies Premium Annuity 8 h No. of Policies Premium life ‘ i No- of Policies Premium Non - Linked Health PensitM k 1 m No. of Policies Premium No. of Policies Premium Annuity No. of Polkm Premium Total Md. OfPo&cics Total No. Of Policies Total Premium <1 r qiate+e-»g+i»fc+m -b+d-rf»h*j«4*n*j M B H B I ■ H H dHKtM M lifliHI ■ m ■H f l H H I M B B B b ^ B ^ B ■IH ^B IB B M M I BM B flB BB IH B H ffl B H H H B B BI^BH M B B M M B I ■■■■ ■H H H B B H P P M H I ■1 1 H I ■■■■■1 te&tMBUM B H I WMMBKBBHBN • BB ■ ■ B H IH B B H B B B B ■B B B H I BBBH BBH ■D B ^B B B i ■■ ■Mill— M IBB...Hi IT' I Mll. I'TMMMfTh WM • BB ■■M W M BIHBBI ■n I BB H i 8NBBHBBI8I iillSiM iSS ■B B H B I ■ ■ ■ IB B B B S BBRBH BB & B nsB B H H H B I ■ ■ ■f l U M B W a b h h h h b i B B H H H W H M H U M i l f l M n K S l B K ^ a i l H ■riUMUNWIIH W i i ’ "i H B ^ u y B i w U h m m U m iU U h o ad H l m m m m HHM BW A B H BBM b h h h KUriHMBHB BHHb b i IBM BB B^i ItnsurerWise Premium -Life -<forWdere) Column Coda Health ♦ sickness a b No. of Policies Premium Accident* disability c d No. of Policies Premium Term No. of Policies Prem Others (PWB) E h No. of Policies Premium Health * sickness * ' -. *■■■ • f Policies , Premium Nan-linked Accident* disability Term •. of Policies Premium Others (PWB} No. of Policies Premium Total No. OlPoScies Total N*> Of Policies Total Premium M i luslness Data (Basedon Premium serviced) - Top 10 Clients (Non-Ufa) Client Name Marine Hull Marine Cargo Motor fire Health Engineering Liabilit' MHc Total No. Of Policies Total Premium Column Code a b < d .. .«. . f 6 h 1 i k i n 0 P q .r No. of Policies Premium No. of Pollcias Premium No. of Policies Premium No. of Policies Premium No. of Policies Premium No, of Policies Premium No. of Policies Premium No. of Policies Premium ciatoe+gi-i+k+m ifr+(t*f*h+jH+n«i j ! : ' ' 1 M H B H B r j _____ | f Z ___ - 1_____ ____ ( j. . . .. 4 i ----------------------- i ! 1 I lefient Wise Buslnew Data im r i on'priiftMum tewictd) - Top 10 Client* (Uf») * Client Name Column Code No. of Policies tfe b Premium No of Policies Linked Health Premium Pension e f No. ofPoMcies Premium Annuity e h No. of Policies Premium life No. of Policies Premium Non-Linked Health Pensio k 1 m No. of Policies Premium No. of Policies Premium Annuity No. of Policies p Premium Total No. Of Policies Total No. Of Policies Total Premium q r ____ _ ....... 1 IC0.IB W l- ■aUn. .. 0.M H ...J , » fr.miurt jUI. - » » g L Client Name Linked Non-llnked Total No. Of Policies Health sickness Accident* disability Term Others (PWB) Health * sickness Accident* disability Term Others (PWB) Total No Of Policies Total Premium Column Code a b c • d e f £ h i ' i k 1 m n o P i) x Source /calculation No. of Policies Premium No. of Policies Premium No. of Policies Premium No. of Policies Premium No. of Policies Premium No. of Policies Premium No. of Policies Premium No. of Polities Premium <^a+c+e*g+i*k+m . ... _ " ........ — ................. . . ...... -----J [^IFT in _ 7 g n ^ 4 ] «TTTcf ^ I T O FOIIMS Business l!lat ■ for Insurance Brokers Ft1t•rs ■ndP ■r ■m ■t■n Y■.ar - • . . . . ' . ka--a-. ~ IMU Cati (!.Hird ofl Pr.mlwm Hrvk..tj · Top 10 Cli ■n'h jNon-llt.J = out ~, OtPoftL'1", r.io 01Po4< , ·.,1,1P,e,.,..,,., . ' ,p,....g• •~•m r., ,_. • i I _: ut rJo OfPot,,.-~, TnDI P,em1wo, . ' THE GAZETTE OF INDIA : EXTRAORDINARY [P art III—S ec. 4] NjiH -if A:5C!!Coni Tioe/D es!*rsa«on Oire-cccr/Parin-er or 5-oie ?<-opr<e?oi O-rector/Farr.-i*!' i. orb . _ _ _ _ _ M OM S (LIFE) Business Data for Insurance Brokers (Life Insurers) _ _ _ ___________ Filters and Parameters _____________________________________ ______ ___________________________ Year | 2005________________] Quarter [_______________ 02_______ 1 Submission On Type Of Premium |__________________________________ J Submission Due Date * Others represents all corporate agents other than banks. For on bghtitf oT Nam e ■>? App-;cai T»tie/'Oesig."iation . J ; v ; 'c;l '■snnn.t'^ 8**ppi Nam e o? Applicant Ticier/Oesignsttori Otre'TOi’-'Psrtnei or Sole Proprietor OSrectOf/Pftrtner PSace Date \ ◄ 84 THE GAZETTE OF INDIA EXTRAORDINARY FROM 5 {L/Ff} Business Data for Insurance Brokers (Life Insurers) FUl■n and Parameters Y■■, 2005 Qu1rt11r Typ■ Of Premium ...._......., r,,-.a..- a, . .. - . - • , .... '"',..,.__.,. "-.-. !llpvttt,., • I" ....... ,.,., ~ • • ....... " ............... ........ -:. • .a.m.. .. " --~~ - • - a.....,.._ ...... - -- - ..,,..,, ,_ , II ' Ill• 1,/ .. j"hl() t ' C ,~ • i.µ, • tlQ •• Othus rep"s1n1s 111 corpor■h! illents oth.r th•n biinks tJi.i..l..iiiJa , T f .- t ... ... ... ... ···F -T Submission On Submission Que Date [PART Ill- SEC. 4) • J [*?FT III— 4] ' ^TRcT W R : 3raTW f 85 ^ -Z.'' ■. A.:':--.' ,,. V " . .,;VZ'; FROM S (NON-LIFE) B u sin e s s D a ta f o r I n s u r a n c e B ro k e rs (N o n Life In su re rs) Filters and Parameters Year 2005 Quarter 02 Broker □ Submission Due Date Cor on Oehaff of 7 ft le / 0 « 5 ^ n B t - o n I - • s. IVisrssTure o f * s e is s e Nam e of Applfcam T(t8e/Des(gn*tion Difector/Partnei or So «e Pro pi ieto t C i i ector/Pa <m e r Ft a c e fcU ' ■ , ^ S li'V \'VA Date " : " - %Z * FORM T D e tails o f G r o u p c o m p a n i e s f o r a n I n s u r a n c e B ro k e r Filters and Parameters Year (Broker J Submission On Type of Firm ................................... 1 Submission Due Date D treccot/Partnei ©■• S o ie P iopr<etor C >rector/Partner p:ace oste E o 1>ta I M j y; ' #4 • 3TTTTmttrf RIOM S (N6N-UFWJ Business Data for lns11ram,11 Brokers (Non Life Insurers) FIiters and Parameteu Yl!ar Broker FORMT 2005 I\, lt'l"Cf • , - '~"""- ! - I I il 11/b)"\Il -~--- -1--·- - -- ---- --- - - - - --- --·- - ---- - -- - -- --- - - - -- ---· - -- --· · -- -- -- - - ---- ,. Details of Group companies for an Insurance Broker FIiters and Parameters Year Type of Firm '---- -------~Broker Quarter 02 •• Place 85 ,. S..bmlnlon On Submission Due Date -•· Submission On Submission Due Date 86 THE GAZETTE OF INDIA : EXTRAORDINARY [Part III—S e c . 4] Printed by the M anager, Governm ent o f India Press, Ring Road, M ayapuri, New D elhi-110064 and Published by the Controller o f Publications, D elhi-110054. 86 - THE GAZETTE OF INDIA : EXTRAORDINARY [PART III- SEC. 4) g .! ~ 0 .. ~ • 0 ~ e t C I 0 • J ~ i: .. i • € • C C : . • • • • 0 • ~ 0 C • • ! • ! ¥ ~ • •I 0 z 0 0 t Printed by the Manager, Government of India Press, Ring Road, Mayapuri, New Delhi-110064 and Published by the Controller of Publications, Delhi-I I 0054. • • 0 •