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I P h i < t i2 P i, r ? i+ £ & > i f H I * # (Z lniusime : nhtM> u t imh O ?n!S>— I II LJh] • ------ - ------ - if ~ {! .I:!, l, n lL 'i> ~ ~"' l~ ~ ~ ~.,. l'I~ ~• ~ ~- ~ ~tj, = t>_.1 ~) /~)~ ="a ll>Rli 1-f'lr, fl-WJ' Ut Ht ~ tj, .I'~ /U!:i.'1, l~h J~ _.,. ~a i'"t,!lla~b lll-'Jf'l"' \lt4J!'~' ~ = / tl.i~ tl'I 121-''i!"l<I> ,a 30 THE GAZETTE OF INDIA EXTRAORDINARY [P a r t III— S e c . 4] 30 THE GAZETTE OF INDIA : EXTRAORDINARY [PART IIl-~EC. 4] I = I< t i ~- ~ ~ ~ 1 • ' • l ~ ! ~ ~~! ~ '1 ,; ,;.. I - I .. i ~- I ~~ :~ ~: ;, ,!~~ . ~ ~I ·' ~ ; L ' I • I. ,, ~ • 1; i i , ,!~ lrJ " ! ' 11 J I.! iit it: It r, ~ ~ . ~ ) 1 1,· I• . ,~ ~ P.- l I'. ~ l i.-: 't ' I,, ~ '- ;,: II' ,~ ~ ' I\ . :l; ';. . I! • ·• •· ~:-- I ~ . ,, . ~ ~ I• , I(, , . . 1.1 :: . - ~ .- ,t.: i.. l-4 1~ ~ - 1., .. ' ~ ... , ::-~ .,.. ... ii I• ,! ' . ,. ' \} ~· If ,. ,.•,. t . l I• IJ r ( -: '~ 1;: . l'1 ' ' I• ·: j •·.-.,_1 . la ' • 1.: I , . -~ . - ,. ,~ i,:i ".: Ii ' . I•, , r· . ~~ j I• ,,- ,- I, • •' ·• I• < 1•, j; I• I• I •. IA , .. : . ~i I~ I• "¼. 1' Ii , .. I• I • I•/!\ 1-. I • l'.i ,_, ' , •• ~ I'<.• . ,_ 1.~ . '·• 11'· ' 1, 1•. I• ,. 11 1., I,• I_., Ii 1, : , .. . 11 1·, I'; I• Ii 1: l ·••• I• I.: 1-: 1-·. Ii ... I~ l Ill 1.H ' . I ,~ J ~ i II Ii i i i if i i I N - "' .. g 15 ~ ~ ~ ~ l r. a ij ~ t I! I I• . I~ i;I t1i I! IJ i-• ••t ;•• :1 • 11 ~t- .. , i i a1 11L1t· ! ;!!? I I I ,1 • I. !wli~l1 EhH> Itfe P>lk [f S n a — III M b ] m |» f i ■5 k 4 u t J fix i t h I f S W >.v . ’ 5 • ' * : , . 1 4 * ; ■ ■ i / life Z * ■ m k i h x y ■ ■ . ■ < m u late 3 ' r \ - ~ > ... : . , ' . . • . \ .. / i f e ^ i U k 1 ' . - - * Jib I ± fe lfc ^y f ' ■ ‘ - ’ .. ’ - - -H . >W lP -»3 4ft,H ie ln > t> ^ ^»Jt3 ln>IQ» h|JJ t h In lfrK / J i k ’C * * i t h H i E>|^IP [ i t j| ie i t h H i . * - 4P \ • o' , ■ •- . . i i ln > P ^ !«*» f r f r f t in <*>»>$> i t f z .. ■ . ,... • ' ' h>*c - £ * h £ J 4 >fc ■'J ‘ f w J. - H £ - l - - ' * l E !;I" L......J ~ ., :1"' ,~,- ... --- 14 ·"·--- i'"-'J.,• ~ . ··• ~ ' I ~~~ !-~ -- J .... 'I, •• . <I ,T - .. ~~ !J::f.G ·, •= .. " ...... - ...:-~---,~ ..• , ·.:• ,• ·r>;•~; .. ;.- . . . ,, ......... ..... . •,, -~ . i-. _..,. .. -: J ,,. __ . .. ,-· , I\...;;;,• • ·, ":<' 1- ' ·-· ~- .,, .-.I' , .•.•. , ~ ... ., ,,v,•: ;# ~ . Cl~ ... ~-~J ~~._:: ,~ .. ~--, i ... ,:::. .. _ -"'" 1.-1! , - ~ .. --.... -~ 2- -~· • I • .. ._, - ::.'J:'J_ ·:a:· .. '.:.. • J(•"' ·.~. .. - - . - ..... .. , , .. ... .... -_.; . ..... ' . .. r? .. • I• . :' ; . . .... - .r.~• ), ' ~ -:- - ., .. .,. ., ,, .. , ' . . - · ... -. I-• .,. •• •·J,,. ' y ·~fa'. rr- -~ ' "k ~-~ .,;;,. .;:~ ... ..• - ~ h'. '' ",.-:j&:•i .... _ • y,:, ! . '> ~ .L :• - - , J •• ·, ~ .·•- ::r.,... ,. .. ...:- 1.~· ..... ~-r- - :-~ .,._. : ~. -· .,.~ .. • JIit . ~ •· - . ~ ;~i \~:~ ltll!2b ~ .- / """1l -"l!Z "'1l21!.l . . ;'I , • . ' . - . .. .':!!JI -"l!Z ~ -~ ,- lilletll . . . »,l!'ID .,.z lllD.:>i,J ;-1 . '· - > .. ~- J /'2l>11~-""t .....,:,i,, 1,;. ,, • . .,. --. "'-":-,aR ~ .l.!:El..!:£.lc...2t!l - . -;-'. ~ .ll>.J1li.:l. "'~-"'JSJ " I .wll2i'J l,~_}.\IE lllt . . .. J.ni.01>1 i;'J!:I. In)~ llij~ Jtl: ~-- .kb lnlN'K / QD ~'E , JIii • .It.II , .. '.ii . ~ l)lt .>!,,UitJi (J, •t~ ~ :_ 'II~: rr.:.~ .Rllll!l)lt141D(a •, - . l • •. ,, ·. ,; . ~·. - - .... .li .lltl,.lll:!~ ~1111 .!t#Au,1 .,. ~ I<: -z - J,>,t<· ~ ~ J:!lt· ~ .. - 32 THE GAZETTE OF INDIA : EXTRAORDINARY [P a r t III— S e c . 4] INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY NOTIFICATION Hyderabad, the 16th February, 2013 / Insurance Regulatory and Development Authority (Third Party Administrators-Health Services) (First Amendment) Regulations, 2013 F. No. IRDA/Reg./9/67/2013.— 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:- * Short title and commencement 1. (1) These regulations may be called the Insurance Regulatory and Development Authority (Third Party Administrators -Health Services) (First Amendment) Regulations, 2012 (2) They shall come into force on the date of their publication in the Official Gazette. 2. Conditions and Procedure for licensing of TP A 1 -• (ii) Reg. 3(7) is substituted by the following: f “A TPA shall seek prior approval o f the Authority for change in the shareholding exceeding 5% o f its paid- up share capital, whether by way o f transfer o f existing shares or by way offresh issue o f shares to either new or existing shareholders. The application for approval o f such change shall be made by the TP A to the Authority in form TPA-5. A return in form TPA-5A shall be filed by all the TPAs within 30days o f the end o f each quarter, indicating the details o f their shareholding pattern Explanation- For the purpose of this sub-regulation “working capital” means the difference between the aggregate of the current assets and current liabilities as on the date of reckoning. (iii) the following Regulations are inserted after Regulation 8(1) as under “8 (1A) Every TPA shall intimate the appointment o f a new Chief Executive Officer or Chief Administrative Officer or Director to the Authority in the form TPA-6 within 30 days o f the date o f the appointment. (8(1B) Every TPA shall intimate the opening and closing o f the branches or change o f registered or branch office within 15days from the date o f change in form TPA-7 appended to these Regulations. " (iv) A new Regulation 11 (5) is inserted after Regulation 11(4) as under 11(5) Where the Authority decides to renew the license of the applicant to act as TPA, it shall issue the same in Form TPA-2A appended to these regulations. Application for issue of a duplicate license (v) Regulation 12 is substituted by the following: “Where a licence granted by the Authority is lost or mutilated, the Authority may issue a duplicate licence on payment o f Rs. 1000 (Rupees One Thousand Only) accompanied by an application in form TPAS made by the TPA. ” M ISCELLANEOUS PRO VISIO N S (vi) A new regulation 24 (2A) is inserted after regulation 24 (2) as under “TPA shall file monthly information relating to Claims DATA in Form TPA 4 (7A) within 15days from end o f each month. ” 32 THE GAZETTE OF INDIA : EXTRAORDINARY INSURANCE REGULATORY AND DEVEWPMENT AUTHORITY NOTIFICATION Hyderabad, the 16th February, 2013 Insurance Regulatory and Development Authority [PART III- SEC. 4] (Third Party Administrators-Health Services) (First Amendment) Regulations, 2013 F. No. IRDA/Reg./9/67/2013.-In exercise of the powers conferred by section 114A ofthe 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 followin~ regulations, namely:- Short title and commencement 1. (1) These regulations may be called the Insurance Regulatory and Development Authority (Third Party Administrators - Health Services) (First Amendment) Regulations, 2012 (2) They shall come into force on the date of their publication in the Official Gazette. 2. Conditions and Procedure for licensing ofTPA (ii) Reg. 3(7) is substituted by the following: , "A TPA shall seek prior approval of the Authority for change in the shareholding exceeding 5% ofits paid- up share capital, whether by way of transfer of existing shares or by way of fresh issue of shares to either new or existing shareholders. The application for approval of such change shall be made by the TPA to the Authority in form TPA-5. A return in form TPA-5A shall be filed by all the TPAs within 30days of the end of each quarter, indicating the details of their shareholding pattern ". Explanation- For the purpose of this sub-regulation "working capital" means the difference between the aggregate of the current assets and current liabilities as on the date ofreckoning. (iii) the following Regulations are inserted after Regulation 8(1) as under "8 (1 A) Every TP A shall intimate the appointment of a new Chief Executive Officer or Chief Administrative Officer or Director to the Authority in the form TPA-6 within 30 days of the date of the appointment. (8(1 B) Every TPA shall intimate the opening and closing of the branches or change of registered or branch office within 15daysfrom the date of change inform TPA-7 appended to these Regulations." (iv) A new Regulation I I (5) is inserted after Regulation I 1(4) as under 11(5) Where the Authority decides to renew the license of the applicant to act as TPA, it shall issue the same in Form TPA-2A appended to these regulations. Application for issue of a duplicate license (v) Regulation 12 is substituted by the following: "Where a licence granted by the Authority is lost or mutilated, the Authority may issue a duplicate licence on payment of Rs. 1000 (Rupees One Thousand Only) accompanied by an application inform TPA-8 made by the TPA." MISCELLANEOUS PROVISIONS (vi) A new regulation 24 (2A) is inserted after regulation 24 (2) as under "TPA shall file monthly information relating to Claims DATA in Form TPA 4 (7A) within 15daysfrom end of each month. " 1 [nm in— 4] ’TO WT3T : 3TOT W I 33 (vii) Form TPA -1 Application of the Grant of License is withdrawn and substituted with Form TPA-1 attached. (viii) Form TPA-3- License is withdrawn and substituted with Form TPA-3 attached (ix) Form- 4(1) is withdrawn and substituted with Form TPA- 4(1)- Attached (xi) Form 4((2) is withdrawn and substituted with Form TPA- 4(2)-Attached (xii) Form 4 (7) is withdrawn and substituted with Form TPA4 (7) attached J. HARI NARAYAN, Chairman [ADVT. 111/4/161/12/Exty.] F onv_T P A _l 45 and wht Application for grant of license Amount in INR i. Name of applicant U. Address details: Registered Office of the company Address 2 Address 3 Pin code District State Country — — I.._..1 L. ± J CltyA own/ViUage Z Z Z Z T E Z D Z E I ..... Hi. Contact Details Phone 1 1 Phone 2 i . ............ ................... i Fax e-mail alternate e-mail ! 2. Details of applicants company a) Date of incorporation as company [ D I 0 } M' 1 M I V I V { Y 1 V 1 b) Registration No. ______ ________ c) Capital Structure Details Authorized Capital Paid Up Capital Issued Share Details 4) Extent of Shareholding by Foreign Promoters ffsrs c a /^-3 1 . . . .1.. [ 'IWT III-~ 4] 33 (vii) Form TPA -1 Application of the Grant of License is withdrawn and substituted with Form TPA-1 attached. (viii) Form TPA-3- License is withdrawn and substituted with Form TPA-3 attached (ix) Form- 4(1) is withdrawn and substituted with Form TPA- 4(1)-Attached (xi) Form 4((2) is withdrawn and substituted with Form TPA- 4(2)-Attached (xii) Form 4 (7) is withdrawn and substituted with Form TPA4 (7) attached Fann.. TPA_J As •nd - Appllcatlon for grant of license ,___,._ ----... ,_-~- ____ ,._ ------_,._-,_TPA-1- ___ .,11,o_,1.,,. __ ----••-----TP•- FormTPA-1 II, Adclr~ detalh: flealtterK Office of thli company -· AddrMtl i Pk>COcle Clty/Town/VIU■1e I..._ _ __, I · · 1-1 I I I· I 1 State ..,,,,.., Cow.lntrv I ii. Contld Del.Ilk , .. aftemabl .. mal 2. Oilt:11llt of ■,iplk■nt1ccu11pany •> Date af incotpcratlon at 1:ompany ID lDlMlMI ·••I• ••I lbl •t'flttradon Ho. I I I I I - Is~ Shani Dat■ll1 J. HARi NARAYAN, Chainnan [ADVT.111/4/161 /12/Exty.] _.,mcunr ln INFi _..___ --1-• - - I ~ ~--------. --- --!- --- 1 -- -·----t:=- ----- ⇒- : - - ----·· ........ ----· j------: ---------+1------= 34 THE GAZETTE OF INDIA : EXTRAORDINARY [P art III— Sec. 4 ] •) Certified copies of Memorandum and AOA Memorandum I ~~ AOA I f) Name and activities of the promoters g) Current Business Activity h) Any Past history of application for license «? Application No. i Date of Submission j Status o f application i Reason 3. Details of Directors Name of director Age 4. Details of CEO* CAO I. Name II. Date of Birth IH. Place of Birth fSggTi DEEEEEE •BSaSfKSSSBSS^MfSESSMSIBaBSIBiifiBBSSEHaXHBOTIMBBBBBi BSSiESIIislSaSiSSSSSlSISiKSBESStiSSSiM SIBSEISi^ESBBB ®»mssw(!«a0eK!is^S5««isiie»iS5»iaBSBaaBaB»s8>BasECTBi ISig^iisMKSiSHSE II«SlS«*SiIi3 EsSBssBsawsaBs assissAssssssa Plncode City A own/Village District State Country Telephone no Fax No v.Passport/ Identity Card No. Date of Issue Place of Issue ; 31^53 m aur rmsm\ 1 3&iMZ .............................i -J/_, 7~,' i-A t' -I * is 31? r2>*i ‘^L JV.; <: 34 THE GAZETTE OF INDIA EXTRAORDINARY [PART III-SEC. 4] •l C.rtlfl■d coplet af M ■mor■ndum and AOA M ■mor■l'\dum AOA fl NarMi ■nd ■ctlwltiat of tha pramotan --:-,-- - --'-----------.--------t--~---------=---1--------I------- •I C.Urrent 11u1lne11 Actfvlty h) Any Past hbltory of ■pplk:ltlon for IUIIH , Application No. D■taof511bmlsslon - Stltul af ■ppllatian J. D ■tall1 of DfrKlot1 4.DatalllofaOACA0 Cty/Town/Wla .. District ..... .,._., f■xNa v.Pluport/ Identity Cln:I •.. D ■t1otl11u ■ PI.ICII of luue -· , .-I (J|l«wp M*|ujn; a$«9|d) pajayo jao|AJ»i snojjeA »m jo; Autdiuoa }ueo||dd» am Aq pafjtqs aq o; sjsoo put u a j pasodojd jo Bjnpatps '9 ,■■■',:■•• 1 ■ : ;'. ■:■■ . ' ;v",i ' ...... /.... ; ■...‘ iK a a a a a a sjj'imii ii*d uoi|cu*m8*h ■HI'IU'.UI 9I|) (O OUJPfJ m o Q o o o i uoRBoynenb iwipaw (a Ajjunco •WS IWW »8*||IA/umoi/Aj.o •pOSUfd £ SI*ippV I isajppv ttwappv sii«j»a **«jppv (q uo«J»d |K>IP»M io 3Ui>N (t :o» isasst **q v d l ui'oqM oj uouad (asjpaw 1° *il*»*a S ■Bi^^g'mis^^jTOWMiBaagaBHiMBjirniinwMMaaBiaBMgMiiBaBgwiBWgagMWiggaBa ^«^'3^i^i®«ig3«K®?£S2aaia^ai3ss!®>^i»«5»!«isaK®s»i.3^sje'ffi;-«saMS5sessais t s v t : •:-'- j. - i iiiim -inn M imwuw $. •„• ’’~ ^ « a ?x sH e :a » £ K :« rs:< 3 « e a i ■ * ■ ■ a * ' y :-y- ;'■■■■■-■ "■ ■;■ -v -.......• • ■ ■ " ffi^5i-^^*ar*sa^& a««855® s?»^M ^sssg^iifi^aae5s.i-ia«®s«!ss!Sr!««3?sii‘<a965se««ssgwi5Ks&?s3 J0}IJ)*!U|U1PV mi»»H to p|»u aqj ui auol-iapun fu|u|«ji i n l a i d aqj »o s||c*aa (q .... .... - ■ - ■' : ■, ■ L — r m :................ .......... - : — ■ T.:,rT-|.:;r:;r,';v- —----- uo|)K>yn>nb 3|uiapasa jo i||BiaQ 'j Ajojsih s||Bjap }uaiuAo|dui3 *a J n i m i m e : £ h M L life, [ p ^ n J5> — H I l t l h ] > I I I I / (ltl~t:J '411\U,Y HH1i) p ■l■,MO 18:>!AJM IIIOjJI~ •~ JOJ MIi~ 1UC3Udd ■ II.A Aq p11J143 ~ a1, 11tc:I pl.II M81 p ■t~.J\111 ~ ltnp,i~ 'ti I I - - --------·- . . . ..,...., ....... ZHIJPP'lf' I ---------------------------+--------~-- . r- .,.. ' I I a -- .... ,. ................ ,.........,,,,.., ____ "' __ ,....,J/ ... .......,,. ...... (1 --~--- -----+---------------,1---------+--------;---- F J- I +-<-I lllllali::lli: ~ ~ - lillb, [P ~ - III 4.lh) 36 THE GAZETTE OF INDIA : EXTRAORDINARY [P a r t III— S e c . 4 ] 7. Declaration •) I am not a minor b) I have not been found guilty of criminal misappropriation or criminal breach of trust or cheating or forgery or an abetment of or attempting to commit any offence by a court of competent jurisdiction c) I have not been found to be unsound mind by a court of competent jurisdiction d) I have not been found guilty of or knowingly participated in or connived at any fraud dishonestly or misrepresentation against an insured or an insurer e) I possess requisite qualifications and practical training as specified by Insurance Regulatory and Development Authority f) I have passed such examinations as specified by Endurance Regulatory and Development Authority g) 1 have not violated the code of conduct specified by Insurance Regulatory and Development Authority h) I warrant that I have truthfully and fully answered the questions above and provided all the information which might reasonably be considered relevant for the purpose of my license i) I declare that the information supplied in the application form is complete and correct For the behalf of Digital signature of Director 1 Name of the Director 1 Title/Designation of Director 1 Digital signature of Director 2 Name of the Director 2 Tltle/Deslgn*tio« of Director 2 I T ~T"T T T l"l " I 1 1 f~ 1 F T ----1 I------ f------------ F I--------- d«. 1...8. 1.8 .1....« . lvi I xi.v.l y ; - . ........ ... Q ,~ , n ' i' i i" i, n i r , r n ~ ~ i r ,~ i : .: i ,1 __ i Form TPA-2A As and When Certificate of Renewal of License (provided by IRDA) Purpose and frequency * This form is provided by IRDA as an acknowledgement of the renewal of license to TPAs. The frequency of this form is as and when IRDA grants TPA license. License No. 1. In exercise of the powers enjoined on the Authority, it hereby renews the license o f............................. ...................................................................................................................to act as Third Party Administrator. 2. This License shall be valid from D D M M Y Y Y Y to D D M M Y Y Y Y 4. This license is subject to the Insurance Regulatory and Development Authority, Act 1999 (4 of 1999), Insurance Act 1938 (4 of 1938) and Insurance Regulatory and Development Authority (Third Party Administrator) Regulations, 2001 and shall not be construed to be in compliance with or in conformity to any other Act, rules and regulations. Place For and on behalf of Insurance Regulatory and Date D D M M Y Y Y Y Development Authority 36 THE GAZETTE OF INDIA : EXTRAORDINARY [PART IJJ-SEC. 4] 7. Dedaration •l I am not • miner b} I have nol been lound 1ullty of criminal mK.lppropriatton or crlmlnal breach of trusl or chuting or fors@ry or ■n ■betment of or 1nemptln1 to commit ■ny offence by• court of competent Jurisdiction cJ I haW! not been fot.ind to bl! unSOl.lnd mind by • court of compt!tent jurtsdictlon d) I have not bHo found 1ullty of 01 knowinaly ~rticlp11led ln or connhted .at ■ny fraud dishonestly Of mlsrl!pt'~t ■tion a111lnst ■n Insured or an insur•r e) I poneH r~uislt• qu1Hfiatlon1 Ind practk11I tr■lnh'II H tPKJfled by lMur ■nce Re1ul1tor, 11nd Dnelopment Authorlt\i f1 I h■ve puH!d such examinations ■1 1p«lfled by Endurance Re1ul1torw and OrYelopment Authority ll I haw not vial■~ the code of conduct specifk,d by lnsur ■nce Rqul ■tory ■nd D~lopment Authority hi I w ■rr■nl that I h ■,ie truthfully and fully an.i;wued lh• QUHtlons 11bov@ and provided ■11 the Information which ml1ht rusoMbly be con1lclered relrvant for the purpose of my license I] I dedare that the lnformalion 1uppll@d In the appllcatlon k>rm Is complete and corred: For the bahaH ol Dl1ltal d1nature of Director 1 Name of the OlrKtor l 11 11 1111 11 11 I 11 I I 11 11 I 111 Tltle/Deslgn1tlon of Director 1 II I I I I II Dlgltal 1t1nalllre of DlrKlor J Name of the Director 2 11 11 1111 11 11 I 11 I I 11 11 I 111 Tltle/D•sl&nation of Director 2 I I I I I I I l Dote P I 9 I M I Ml • I II Y I • I Form TPA-2A As and When Certificate of Renewal of License (provided by IRDA) Purpose and frequency This form is provided by IRDA as an acknowledgement of the renewal of license to TPAs. The frequency of this form is as and when IRDA grants TPA license. Form TPA-2A License No. 1. In exercise of the powers enjoined on the Authority, it hereby renews the license of ................................ . ................................................................................................................................. to act as Third Party Administrator. 2. This License shall be valid from I D I D I M I M I Y I Y I Y I Y I to I D I D I M I M I Y I Y I Y Y 4. This license is subject to the Insurance Regulatory and Development Authority, Act 1999 (4 of 1999), Insurance Act 1938 (4 of 1938) and Insurance Regulatory and Development Authority {Third Party Administrator) Regulations, 2001 and shall not be construed to be in compliance with or in conformity to any other Act, rules and regulations. Place Date !DfD!M!M!Y Y VY For and on behalf of Insurance Regulatory and Development Authority [■*TFTIII— 4] ■HKC1 ' t i l : '3 1 ^ 1 1 ^ 1 ^ ''! i. Name of applicant il. Address details Pin Code District State Country i 1 i r i 11 I .. I . I. ..L L -V 1 X I- ~ j ■ S AirifaPr»d«rii] City/T own/Village V i ffl Z3.... Hi. Contact Details Phone 1 Phone 2 e-mail alternate e-mail n ~ 1 - I - f — T Tl" T ~ T~’T i Ti c e i ii i • i - [ i rr i ~ T~n .~ii r ~ m - b b B - i i ii i i I- i. ii i m -i a .i i h b a i a i h i ■ i i . : i n i m i m b h i f;-§g--ttw b h b b b b s u i — ■ i ii m m i b w i 2. Details of applicants company a) TPA License No. b) Date of license I 'D t ' D* c) Date of Expiry c) Capital Structure (M l M I I <1. 1 I 'V - ItI iwi m i r r r » i » i»i T - o s * ~ - t : : v . • : Authorized Capital Paid Up Capital Issued Share Details d) Extent o f Shareholding by Foreign Promoters Distinctive No’s I Face Value Total Amount I ['!WT lll-~ 4] '°""-~J ,., __ ~ for r-.wal of license (To be furnished by TPAs) LP,,,_ol~ J. N ■me of 1ppllc:1nt ti. Address details ...... , Pin Code District Stlle Country m. Contact Det ■lls PhOM 1 Plione 2 e-mail ■ltern■t• e-mail 4, ..... :--,~,1L~• ... l-~,~l;!_:7,a ... :~1:v ,., .... 1...·.~. --:,~.:i ·1.·,:: .. •• .. !.""!1'1r::1 i~t ,_J._•• .. :. ,": • --•••,. .... ~I •' ,' ';",, ••• • ,•••• .. if 1 1:•4t,':t ~\ r.- ., ·.; ... -:1 ~:, ~ ,1 :.• ·:· · -~,. :,;:, ,; ". , ~ "...' \!"' c . ·~• : ~ , _. ~ _ t , I..: •-.-- • · i~ t" ... : '11!~,..•_!._~ .. ll _ J:_.,._ .. ,,.:~~ .•:: 1 ".:.•'·",,-,.-{,;""!..~t.~•:... .. ·:·:---, ?'".:.....&'L1Uli 1'4" :tt:1~-~~~!\.•'.!. ,:Q.7 :-r-,•.,_~;:J~' ,.:-·2 u.-,:• .r:... r:,::. er-.,, ·•1~,~,r~:w- ~..tf.! ... ~ .:i, I.' ;i II~=.,, e-!JI"!!?. ~ ,o.::. (?ti~ :.s..· •• <~ \vlltl'.I' 2:.111."- ,;_.;, wt'CU!J.l'i.1J Oty/Town/Vllla1e II 2. Det ■lh of ■pPllcants company ..._ .. , ■J TPA LktMI! No. •~ -·-,--: -~r:i:Jr:-:.I.T--;t'T'!'9'~;:r;:--r•~,..,~•:--s:~7."":~~ :.•_ ~-,, ~~ .,_. '-J.» .......!l..:rJ· •~ ~~ .. _ :-!...·~ l.'....i.~ ..t•_! ._\,& ~= ---=•n · -'~~--~ ~ ~..:., --~ !.."..:- ~r,: b}D ■t■oflicense ~ iMf 1-1 •f f#•hl c)D ■t■ of Expiry c) C■plt■I Structure l11uad Shara Det■lh I ' I ' I . I I - I ---7 - I - I I d) Extent of Sh ■reholdln1 by Foreisn Promoten I i NJI,, I H E U A A t l I t U r I N D I A : fc A 1 K A U K U I N A K Y |P art ill— Sec. 4J Return TPA_4 (1) | Yearly Details of TPA Admin - - J ' i S ® ! ! Purpose and frequency The return captures the existing administrative configuration of TPA. This form includes data on directors, CEOs and CAOs. The data collected from the form will be used to track the changes in the administrative changes in the TPAs. As required by IRDA (TPA) Regulation Form 4(1) The frequency of this return is yearly Filters and Parameters Year I I TPA Name Name of directors Age Address ^ ate ° j° m,ng as other Directorship Date of Exit as Director telephone no e-mail __________________________________ ______director_____ | ______________ | ' • |_____________ _______ Column Code I a b c d e f e Directors’ Details CEOs’ Details J # Name of CEOs Age Address Date of joining as CEO Qualification 1 Date of Exit as CEO'S telephone no e-mail Column Code a / 1 b c d e f g 1 ________ 1__________ _______________ ![ - .1L __________ 1 .................................. 1_______ J 1- J Chief Administrative Officers’ Details 1 Name of CAOs Age A . . Date of joining as Address CAO Qualification Date of Exit^as CAO telephone no e-mail Column Code \ a b c d e f g \ ■: r . : ! I . : , . ! - . . 1 1____ . 1 L________1 Auditor's Details Name of Auditor Particulars Address Date of appointment! Remarks telepnbrtie nr I 1 ! Internal Auditor I 2 1 Statutory Auditor .>O lt1t \JALtl lt Vt' lNLJlA : t:,XlKAUK.lJINAKY Retura TPA_4 '2J I Yearly I Details al lPA Adml•l$tratfve Coriflgunitton Purpose and frequency The return captures the existing administrative configuration of TPA. This form includes data on directors, CEOs and CAOs. The data collected from the form will be used to track the changes in the administrative changes In the TPAs. As required by IRDA (TPA) R"lulation Form 4(1) The frequency of this return is yearly FIiters and Parameters Year TPAName Diredors 1 Details CEO.' Details · I • · · • 1 • • • I . . , f . · • . I · ·, , · , • . . . jPART Ill- SEC. 4J ~ ... -· --"'--- ______ :~ . -· ~ . . - - . - : I Chief Administrative Officer5' Details Auditor's Details :: Particulars Name of Address Date of appointment Remarks telepliOn-e~nr t• m,td _ _ • Auditor • -· _ _ l __ . . ' ' 2 Statutory Auditor [*(PT IH — 4 ] ( ■RTCcT TTSPT^T : SRTraRTiT 39 i ....... wjmSM f f i l l s l f e i f e a & ? / « 3 M p A « Purpose and frequency Amount in INR » Name of the insurer date of commencement o f contract Validity of contract . Premium Serviced No. of lives serviced Remuneration basis Remuneration amount Nature of service provided No. of claims processed by TPA during year No. of claim‘s_ pending w ith TPA at end of the year No. of instances when the float was replenishe d beyond 7 days Column Code a b c d e f g h i j • * Basis r r v ' v ■ • - . , ,. fla t Rate .." .........■ j • ' .............. J Slab Rate , . ■ - s i* * •< ' __ __ __ ' ■' T 7 ~ Date of Nature Validity of commencem ■ ent of Address arrange ment contract Column Code I Enumeration Details of standing arrangement w ith Hospitals/Doctors Remuneration (Revenue per service) Premium Serviced Name of Doctor/H6spita contract % Basis % Basis Flat Rate Slab Rate 1 [ -i:rrT m~ 4 J '!Wcf cfi1 ~ : ~ ,urposa and frequency '111111.....,,, ltQIICUmllhe lllli. on tl>econtncl'I olfl'At wM in,.,.,. and_llolpltah./docton aJo,,_ "h thellllt• onclaln,s ,._Md 4urln1 ..,_,...., At roqwocl by MIOA (TPA) _.i.- form 0{2) 11,elr...-,ctaftlwr-11,-.,1¥ TPANanM c-.ct- ~-··-- --t-----1 Amount in INR ---- -------,.-----.----..--- 1 Enumeration Oet ■llt of st ■ndina ■n ■na:em.nt with Hospital1/Doctnrs ---+------+------+----t-----+---t-----+----l --i----- " Basis Flat Rat@ Slab Rat@ 39 I I I I 1. Yearly i § t m i Return to Menu of Outstanding Claims ( outstanding for more than 6 months) for TPA i, SySIS J 'j * £ ■ 111 Purpose and frequency This return captures the detailed level information about those claims that are outstanding for more than 6 months. ! This return is an re-engineered form at based on the existing form at for collecting the detailed level information about the outstanding claims. As required by IRDA TPA Regulation Form 4(7) The frequency of the return is yearly. Filters and Parameters Year Name of TPA # Claims No. Claims Type Insurer Date of registration of claims Claim outstanding for (no. of days) .......... Reason for outstanding Column Code a b c d * Source/Calculation =Today()-c | Benefit Further Details Awaited from Policy holder/Hospital .. . Cashless •». ' ' . . . . ■ . ... Float money awaited from insurers i Reimbursement ' - -............... , i • ....... - • ■ - - - ------ — . — . . . . . • . v . .• ■ / \ '■ . . ‘ : ■ ■ 1 ....... - • • .......-..............■! • . ■ :• ■ ' .......... —------------- -......w •* ■ - . THE GAZETTE OF INDIA : EXTRAORDINARY [Part III— Sec. 4] ~ ~ l7} I Yearly I Retum to Menu •If · · utstanding Claims ( outstan · e Purpose and frequency This return captures the detailed level information about those claims that are outstanding for more than 6 months. This return is an re-engineered format based on the existing format for collecting the detailed level information about the outstanding claims. As required by IRDA TPA Regulation Form 4(7) The frequency of the return is yearly. Filters and Parameters Year NameofTPA # 1c1a1ms ~~ 1 . 1Cla1m outstanding for (no. of days) 1 Reason for outstanding I C aims I I ----~--- - -- --- -- --- r - ------ -- --- --------.------ Co/um c I d I e , . ~f~::__ Date of ,egist,ation of , . . ; Source/Cale I ----r----=-T-o-da_y_(-)--c-----1 ----- - - - - - - - . I Further Details Awaited from Benefit - I Policy holder/Hospital I Float money awaited from I Cashless - i insurers - Reimbursement i ! . . I I I I ' r - ' •. l ~ I i I I - tTl ~ 0 :;ti 0 z l ► ~ T (JJ Pl ~ [*TFT III— 4] Purpose and frequency This return captures the claims data for TPAs. The form captures the claims from policyholders, claims from hospitals and claims in aggregate level. This form is re-engineered on the basis o f the existing claims data collection form in TPA Annual report. The new form captures more detailed level information about the claims data for the TPAs.As required by IRDA (TPA) Regulation Form 4(7) The frequency o f this return is monthly Filters and Parameters Year Month Amount in INR Aging o f pending claims* Cashless Claims Reimbursement .Benefit Based Total # Particulars No. of claims Amount of claims j No. of claims j Amount of claims No. of claims j ................................... Amount of claims j No. of claims Amount of claims Column Code - a b j a j b a . b I a I b 1 Claims pending at the beginning of the month _ New Claims registered during the month ] v ’ ....' ' 3 Claim settled Fully and serviced by Government Hospital . 4 Claim settled fu lly and serviced by Private Hospital 5 - jClaims settled partially | 6 j Claims repudiated 7 Claims closed due to other reasons 8 Claims reopened 9 Claims pending at the end o f the month j __.. ' ■ ■ ' J P = Particulars Column Code Cashless No. of claims Amount of claims d b Reimbursement No. of claims Amount of claims -------------- ------------- a b Benefit Based No. of claims Amount of claims a b No. of claims -- ...r — ... a Total Amount of claims b l Claims pending for less than I month ! : v . ' _ _ 2___ \.Claims pending for 1-3 months ______ _ _ 3 ' ] Claims pending for 3-6 months 4 Claims pending for 6-12 months 5 i .. Claims pending for 1-2 years claims j>ending for more than 2 years — __ | * Reckoned from date o f first intimation Aging o f settled claims** Particulars Column Code Cashless No. of claims Amount of claims a b Reimbursement No. of claims Amount of claims a b' Benefit Based No. of claims Amount of claims a b No. of claims a Total Amount of claims b l Claims settled within less than 1 month ^ ; V / .'/'I 2 Claims settled within 1-3 months 3 Claims settled within 3-6 months 4 Claims settled within 6-12 months . "■.......................... 5 jClaims settled within 1-2 years I 6 iclaims settled within more than 2 years ** Reckoned from the date o f receipt o f last requirement Aging o f repudiated claim s*** Cashless Particulars No. of claims Amount of claims Column Code a b Reimbursement No. of claims Amount of claims a b. Benefit Based No. of claims Amount of claims a b No. of claims a Total Amount of claims b 1 jClaims repudiated within less than 1 month u " " 2 jClaims repudiated within 1-3 months j 3 Claims repudiated within 3-6 months 4 j Claims repudiated within 6-12 months _5 Claims repudiated within 1-2 years 6 j claims repudiated within more than 2 years * * * Reckoned from the date of receipt o f last requirement 6 S S G t J l Z - l l [ ~lflT III- ~U,S 4 J 'qffif cfiT ~ ' 1'11,pose and frequency . ' This Ntum ca,:itun11 the clalms data for TPAs. The form captures the claims from policyholders, claims from hospitals and claims in aarea:ate level. Thb form is ,...,..1n .. red on the bislJ: or the eidstln,: claims data oollft(;tkn1 form in lPA Anni.$! report. The new farm aptuns more d1talled lavel informatiori about the claims data far the TPAs.As required by IRDA (TPA) Rqulation Form 4f7) ,The fn!quent";' of this return is monthly FIiters and Parameters Year TPA No.~--IMfloet_,..,..,..._...,....,,11ays~----~ Month 41 Amount in INR Cashless Claims R{'1mbursement Benefit Based Tota, No of claims Amount of clauns No of claims Amount of claims No of claims Amount of claim s No of claims Amount of claims t, Particulars Column Code a b a b a b a I b I Claims pendin1 at the be1inning of the month ---i- 1New Claims re1iste~d durin1 the month I ------- -- -------<-·-----.- 3 jClaim settled Fully and serviced by Government Hosp_lt_a_l -t--- - --·t-------- t--------+-----+---- -~--- I Claim settled Fully and serviced by ~~~s~~J ____ " ____ ~ _ S Claims settled partiaUy_ --- ------1------+--------t-------t-------+------+---------+----+--------< 6 1 Claims re udiated --- - 7 !Claims closed due to other reasons B Claims reopened - -------+-------+--+--- ·-----· >--·------+ - 9-JC1aims pendin& at the end of the month ____ -=-------~------- - ---+------- t---------+--- ----+- Aging of pending claims• • Reckoned from date of first intimation Aging of settled claims .. -----+---------~---4----------: ~ - -I I - - ~ =--"=~= ~~~-- -+----+------+-----+-------+-----1- --~L I . . Aging of repudiated claims• .. _ _ • Ca~hless • Reimbursement • Benefit Based _ _ _Total _ :, Particulars • No of claims . Amount of claims No of claims Amount of claims • No. of claims . Amount of claims No of claims . Amount of claims Column Code a b a b a b a b - ,- I - -- FORM TPA-5 Quarterly TPA Share Holding pattern S5< • J- C » ; ; Purpose and frequency To collect data on details of capital structure and shareholding pattern of TP As. This is new form. : The frequency of this return is quarterly its : ■ ■■■■ . ■ : I I 1 ^..... Filters and Parameters Year TPA Name \ V ~ I Quarter Shareholding pattern # Name of Shareholder Address Quantity of shares Nature of share holder % of shareholding Date of association with TPA Remarks Column Code a b -d “ m e f Foreign Domestic rrr?7.‘ T- ■ ■ : | 1 - J‘. - ' ' t : : ■............... rV ' V;- i :\ ■ ii *-% - '.*■ *v .• •' * 11 . V . 1 ' r i : \ ' t Amount in INR # Particulars Amount Column Code a 1 (Working Capital 2 Service Fee Due Amount ; FORM TPA-5 Quarterly 1.PA Share Holding pattern ---~.__ _________ ......__,.. __ .......___,_'-',_~------- Purpose and frequency To collect data on details of capital structure and shareholding pattern of TPAs. This is new form. The frequency of this return is quarterly Filters and Parameters Year TPAName Shareholding pattern ". Amount in INR Quarter - [*TFT I I I — 4] mm °FT w r a : s ra rw i 43 New Addition Purpose and Objective This form is used to capture the details o f the capital structure o f a TPA Frequency is as and when change occurs Filters and Parameters As on Date 1 ~1 Capital Structure Am ount in INR Particulars | Amount Column Code | a 1 Authorized capital 2 Issue Capital __ 3.___ Paid Up Capital 4 Free reserve excluding re-valuation reserve ____ : * ft Shareholder Name Total Equity Share Capital % Holding Column a b c 1 j Indian 2 [Foreign Direct I . - . r T T T 3 | Foreign Indirect . 1 Shareholder Details ___________________________ __________ Date: | n : ■7—'^ -V Category o f Shareholder (Foreign Direct/Foreign Indirect / Indian) Name of the shareholder Address o f the shareholder Business or Profession Shareholding as at end of reporting period (Number) Shareholding as . at end o f reporting period (Amount) Date of changes in shareholding during the period Particulars of changes in shareholding during the period Column Code a b c d e f g ___1__ . Purchase 2 Sale 3 4 5 6 7 ___;________________ For the behalf of Digital signature o f Director 1 Name of the Director 1 Title/Designation o f Director 1 Digital signature o f Director 2 Name o f the Director 2 ■_____■ _____»• ■' ' _____ • ' Title/Designation of Director 2 Date . _ - . wmmmmmmm m ___ :____________ DPMMYYYY [ 'IWT III-~ 4] Nitw Addition Pur!XJ"" ■nd Objective This farm ls used to capture the details of the capital structure of ■ TPA Frequency Is u ■nd when cha"le occun Filt■rs ■nd P■r■met■rs Alon Dat■ TPA 9 P■ld Up C■pltal ~ Free reseive excludina re-valuation reserve FOi " Shareholder Name Total Equity Share % Holding • • Capital . Colvmn a b c 1 Forel1n Olr■ct S : Forei1n lndlN!d For the behalf of Digital signature of Director 1 Name of the Director 1 Title/Designation of Director 1 DiRital si1nature of Director 2 Name of the Director 2 Title/~signation of Director 2 Date 43 2. Details of CIO *CAO i. Name H. Ditto*Birth v. Address & Contact Address 2 Address 3 I ■ -..'I - 1 1 1 I ' QtvAown/ViHa*e H B 8 B H B K 8 B 3 | owrtc Country g — M ^ i 8583 v. Passoort/ Identity Card - n i S B I E ggggggga CT] I—I...- 1-4 —-H - T f f ....I.......H- Date of Expiry I » -I f g H j S g I BB KsumR Authority e. Employment details History f. Details of academic qualification l) Details of Associate ship /FeBowshipexaminetto* conducted by Insurance Institute of India M Detaih of the practical Tralninc undertone In the field of Hearth Administrator For the behalf of Oiftital signature of Director 1 Name of the Director 1 *1$ THE GAZE1TE OF INDIA EXTRAORDINARY I ,-.-~~~~~~,-- .,, .,. ·~ .... ~ .r.: c-....... .,_.-__ ;...::.•~--•..-7J14;.<,,~,11,,;.-.,,.,. ...... •• _.. ·• -- ... , ~ ,_ __ • , ~-- :-::a1<1:1r,.'J1 .. C!:.:,~- -;- ••• , ~t •• , ,. .·._=--t ._,__ ___ 1U :--;r-- ~ ,._ ..... .., ~--r-; .. -,____,.r : ~-- - · · !. r - .:' LI- -""'" ■ .,('{(I'll .. ··.-...._,''°' -~~ . t ... ~1,•z ·• l ., •- Tl~\.•,_ 1. r.._ ,.: \ .. _ •• "1 If!> .. ~ ll,....j.......Z...:~...z.1'8:i.Ul&J:..:::liia~~J111 .4: "' .. _ 1.•.· ~ ~ ::-.,,. :. d,~ - ~~,..,..,..n• ~--Y- ,..,_,, ~ .. , ... : ~-.• 1.,.,.. __ ,..,-. .'1..llP...__1 r..._·fY.,,. - ... • • • ~ • ..... ~=>--· .... '···- ............. .,. ·• . . .. ... - '' . • J. ... - '!.l' - • a.,. ' ·• - ' -:- . 1. ... I,. .. ,/ --- ., fJ IC' J ►---Y-,.. •J ~-- ..-..... 0 I •,I._. .., • • t ,,.. , 10 '!'t, 't \. ,._ -----s.•::m.• .J•• =~• 't'C: ~-••''•L- I,_:_.. L ..... v""1111a11/ldifflljtwC..1d en~ ..,..-ra:,..Qlla~••--e~Mrur-.,.., l....-__c:..,. '1-..!.Ma."1'1.l"J. r-: ... , ...... ot • L a::11~!'W1111c,r;-.. Jt~ --• ..... -, , .. ~.:=".1•-:;.:;. II,',• ·r !"'I,. s:. ~~ .. ..,i~,,.....,r-.~ .. ..,_..-~~ ........ _......,~ •'I.•.-~-~ '1r~.J."'-"' -31'.~ NIUllfl&'".....,_., ••-- ~•-:"C"" ·; -•~ .Z .,._~ 1.nr-:...~rs...-• ...,r:., ~ s•s.::a,~r• :._•..J •t-a.ci- ... :.w~, ~---+---------+-------------,--------..--~--'..L-------< -- I i&biNFQii§ hi Datall ■f 1t11 ll'Kllai 1 .. 1 ...... ., .... ,. ... Ill tlw llaW ■f M■.0. .........._, - I .. ~ •1,-V '~ "<"•· , . ]i;T---_1 •• _'111!"--. ~ • · • r •• r · '-A .. _,. - • _;: . :- • • • ,. -· ~ - ~1'J • ' --:. I .... • • .. J ,_- • a - • , C, r\ I ,. : •.," ":.,• I C.-i,,. C.. • a. • • , "' ••• ,. •· [PART nl- EC. 4] V * OJ i P ■H H ■K m m M M O T N M B«Ba^«egaB>aiBEaa^ig»!a»egs?Bi^gBaBaBKMfiajqwyliSSiESSBISiBnnnBMBHBHESMIDM B H 8 H l a m M H i i msmm a - rzsm. mi mm mm m g s as •V*_wmmmb warn gb m mm m am i ... m b a Form TPA-7 As and When Inform ation on opening/closing branches, change of registered/branch office New Addition Purpose and Objective .' This form is used for capturing the details o f a branch and registered office fo r a TPA The frequency is as and when Filters and Parameters As on date f _____ _______ Branch Office Details . ft Address o f office Region C ity/T o w n / Village State Person in Charge No. o f staff . ■ Date of Opening of Office Whether in operation or not (Yes/No) Date of Closure (IF h = ’No’ THEN Date of Closure ELSE Blank) Column Code a b c d e f g h 1 1 ■, .... *. .......... ' I ■ . j i ■ ' .... . . . ........................ i count (Rows) ------------- :........ ■.... ....-........J . - .. .. ■■■"■ \ m m *. ;5 m m - State Person in Charge | No. o f staff c d e For the behalf of Digital signature of Director 1 Name of the Director 1 Title/Designation o f Director 1 Digital signature o f Director 2 Name of the Director 2 Title/Designation of Director 2 __ :__ ..___ :____ g m a - — - ' - . • ■ - 7 • . V - — ■ ■ L*TFT III— 4] 1 *TRcf TT3TO --- ~---...... 1 Form TPA-7 As and When Information on opening/closing branches, change of registeredflSranch office New Addit ion Purpose and Objective This form is used for capturln1 the details of a br.anch and r111isterad office fer a TPA Thi!! frequency is as and when FIiters and Param~ters As on date Br■nd, Offlce Detall1 Date of Closure Date of Whet he, 1n City/ Town/ , {IF h - No # Address of office Re11on State Person 1n Charge No of st.1tf Openmg of operat,on or not VIiiage rHEN DatE" of Closure Office fYes/No) ElSF Blanll:J CDlumn Code • c1 • b c • d • e • f • g . h i ---- - +-- ----+-----;-----+----~-------+-----t------t-------+-------- .. l •- 1 &,f.ri,,-.,, n f nff,r, Rr11;,on • • ~tate ,. Person ,n l.harge No ol staff C oh,mn ( odr ., b c I d e For the behil tf of Oi1itill si1n1ture of Director 1 Name of the Director 1 Title/Desi1n1tion of Director 1 Oi1ital si1nature of Director 2 N~m• of the Director 2 Title/0ui1nation of Director 2 0.. - 46 THE GAZETTE OF INDIA : EXTRAORDINARY [P a r t III— S e c . 4] New Addition 1. Particulars of applicant i. Name of applicant Amount in INR ii. Address details Address 1 Address 2 Address 3 Pin Code District State Country iii. Contact Details T ' i ' i — r -1 cityAown/viiiijge»1" V 1 . — ^ 1 I J_Z ..J__1— L - L~] Amnachal Pradesh] Phone 1 Phone 2 Fax e-mail T ~ T L._ J . ..1 - L .1.1 i I tm a ts m - i i ■ .1 i i ' - 46 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III- SEC. 4] Form TPA-8 As and When Issue of Duplicate Certificate of Registration New Addition Pwposeandfnllpnty . This fonn Is submitted by the TPAs for 1pplyif11 Duplicate license. This fann ls submitted 1D !RDA. This form ii r~ based on the rxlstln1 TPA·l form with some adlltionll ,nforlllltlon an theblsis of the pps Identified. ThlS form is u5l!d Incl 'Mhl!ll compan apply for Duplicate TPA lie Amount in INR Ii. Address details Address 1 Address 2 Address 3 Pin Code District State Country iii. Contact Details Phone 1 Phone 2 Fax e-mail alternate e-mail i i ' i i i i \~ n ~ i 2. Details of applicant's license a) TPA License No. 1 1 i 1 J fete! > ■ - 1 1 r 1 I..... : ■ ■ • b) Date of license [ D 1 P 1 - [ M 1 M~ y :r V 1 c) Date of Expiry 1 D j D 1 - 1 - M j M [ 3. Reason for loss of the original licence / certifigjtRjst O Mutilated Loss Description For the behalf of y m m i h b Digital signature of Director 1 ------------------ 1 - g - B la Name of the Director 1 g w iiH f if lw ia ir iif !™R B w'iPl m m m i n a i n i B B i n n f f i i i i a i i a H m i — mm w m m M M M w m iw m wm Title/Designation of Director 1 Digital signature of Director 2 Name of the Director 2 Title/Designation of Director 2 ■ii ■ ■ ■ ■ ■ I ISM. , dl ft4n : : Mi’i1. ’ : SS^BS 8M9H: I I I I I I I T Date [ D | 0 I M | M | Y | Y | Y | Y . \ is E.hH> life M t [fr g n is> — tfl Itlh. ] I alternate e-mail 2. Details of applicant's license a) TPA License No. b) Date of license c) Date of Expiry 3. Reason for loss of the original licence/ certlfi.!,111,st O Mublated Loss Description For the behalf of Digital signature of Director 1 Name of the Director 1 Title/Designation of Director 1 Digital signature of Director 2 Name of the Director 2 Title/Designation of Director 2 Date J) .