Insurance Surveyor Examination Application

[Image omitted. See the official document.]

INSURANCE INSTITUTE OF INDIA
Universal Insurance Building, 6th Floor,
Sir Pherozshah Mehta Road, Mumbai - 400 001.

Tel. : 022-22872923
: 22874722
: 22894800
Fax : 022-22873491

APPLICATION FORM FOR INSURANCE SURVEYORS EXAMINATION

ROLL NO.

(If you are fresh candidate please leave
it blank, else write your Roll Number allotted by III)

IRDA Enrollment No. & Date

Photo

1. Name : _______________________________________________________________________________
2. Address : _____________________________________________________________________________
   _____________________________________________________________________________
   City : ________________________________ Pin : _____________________________
3. Qualification : a) Academic / Professional : ___________________________ b) Inurance : ___________________________
4. Communication : a) Telephone : _________________ b) Mobile : _________________ c) Fax : _________________ d) E-mail : _________________
5. Preference of Exam Centre*
   1. __________________________________
   2. __________________________________
6. Date of Birth : _________________

(*For Centre refer centre code list which is given on the reverse or see page 17 of the Examination Handbook)

7. Subjects opted for Examination :

| SUBJECTS | Section-I (S-1) compulsory | Fire (S-2) | Marine Cargo (S-3) | Marine Hull (S-4)* | Engg. (S-5) | Motor (S-6) | MISC. (S-7) | L.O.P. (S-8)* | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | Please Tick | | | | | | | | |

Fees structure : Admission Fee - Rs. 150/- (only for fresh candidates), Examination Fee - Rs. 250/- per paper payable by Demand Draft drawn in favour of 'Insurance Institute of India' and payable at Mumbai.

8. Payment Details :

9. Practical Training Details :

I have gone through the Examination Hand Book and Agree to abide by the Terms & Conditions / Rules & Regulation of IRDA and Insurance Institute & India mentioned therein.

(Signature of Applicant)
(Signature of Trainer)

10. If you have been already licensed by the Authority, (if yes) Please state category: __________________________

*Examination for Subject (S-4) - Marine Hull and Subject (S-8) - L.O.P. will be held at following centres only - (1) Mumbai-108 (2) Delhi - 112 (3) Kolkata - 121 & (4) Chennai - 132

P.T.O.

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EXAMINATION CENTRES CODE LIST