Agent Application Form

Agent Application Form
Application Type : New Transfer URN NO :
Channel Type : Agency Motor
Branch Name: Branch code:
➢ While providing signature, please ensure that the sample signature is made within the space provided
➢ When pasting the photograph, please ensure that the photograph is pasted exactly in space provided
➢ Please note that the application would not be accepted if above two points are not adhered to
FORM I-A/B
APPLICATION FOR APPOINTMENT TO ACT AS AN INSURANCE AGENT
(with a life insurer OR general insurer OR Health insurer)
To,
Raheja QBE General Insurance Limited.

Ground Floor, P&G Plaza, Cardinal Gracious Road,
Andheri -East, Mumbai 400099- India
Dear sirs,
I request that Appointment to act as an insurance agent of your organization may be granted to me.
I herby declare that particulars given below are true and that the APPOINTMENT for which I apply will be used only by
myself for soliciting or procuring insurance business for your insurance organization.
1) Name:
2) Title: state 1 if are Mr.:[ ] 2 Mrs.[ ] 3 Miss [ ]
3) Father’s/Husband’s Name:
4) Full address:
House No
Street
Town
District
State
Pin code
Mobile no
Email id
Aadhar Number
PAN Number
5) Date of birth (DD/MM/YYYY) Attach age proof :
6) Education qualifications. (Tick the right box)

Class X Class XII Graduation Post Graduation Others
Raheja QBE General Insurance Limited (IRDAI Registration Number:141 CIN: U66030MH2007PLC173129 Toll Free: 1-800-102- (RQBE) 7723
Registered & corporate office address: Ground Floor, P&G Plaza, Cardinal Gracious Road, Andheri -East, Mumbai 400099- India
7) Give particulars of pass in pre-recruitment test conducted by the insurance institute of india or any other
examination body:
Name of the examination body

Candidate’s name
Candidate’s number
Centre of examination
Name of the exam passed
Date of passing
8) Furnish the details of any insurance agency in force or ever held by applicant:
Name of the insurer Agency code number Date of Appointment Date of cessation of Reason for cessation
as an agent agency of agency
*please attach agency cessation letter issued by the insurer
10) Details of other insurance related activities undertaken, if any:
11. I declare that----
a) I have not been found to be of unsound mind by a court of competent jurisdiction

b) I have not been found guilty of criminal misappropriation or criminal breach of trust or cheating or forgery or an abetment of or attemp to commit
any such offence by court of competent juridiction
c) I have not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or mis-representation.
d) I am not involved in any insurance intermediation business other than as proposed under this Application
e) I shall abide by the policies and procedure(s) of the Company and code of conduct as prescribed by Insurance Regulatory & Development Authority of
India (IRDAI) from time to time at all times and shall not indulge in any unfair activities including corruption, money laundering etc
f) I am aware about the provisions relating to rebating and shall not involve myself in any such activities, which amounts to rebating as per Insurance
Act 1938 as amended from time to time
Date: Yours faithfully
Place:
(Signature of applicant)
Notes and instructions
1. The application should be filled in Hindi or English language

2. Any alteration or correction made in any answer to the questions in the application should be initialed by the applicant.
3. An applicant must be at least 18 years and above of age on the date of the application. The applicant shall furnish the proof of age
4. An applicant shall furnish the proof of pass in the pre-recruitment exam conducted by an examination body duly recognized by the insurance
regulatory and development authority of India.
5. The following document should be attached with the application as per checklist on last page of the application form.
Candidate Personal Details
1.Gender Male Female
2.Marital Status : Single Married If Married, Anniversary Date :
3.Basic Qualification: Roll NO Board Name
4.Highest qualification
5.GST Number (Optional)
6.Have you ever been associated with Raheja QBE General Insurance Company Limited? Yes No
If yes please specify
12.Are you a relative of any employee of Raheja QBE General Insurance Company Limited? Yes No
If yes furnish name & relationship
13.Are you eligible for tax exemption under section 10(26) pr 10(26AAA) of Income Tax Act,1961? Yes No
If yes, please attach the proof.
14.Are you Politically exposed person? Yes No
Training and Examination details
Training mode: online offline Location (city) Institute
Examination mode: online Body: NSEIT Other
Location Language Exam date
Relationship Manger details/signature And Checklist of Documents Submitted
I certify that I have personally interviewed the applicant & conducted the applicant profiling & confirmed that the details
mentioned in the agent application form is correct. The answers given in the application are true and correct to the best of my
knowledge and applicant is suitable to become an agent with Raheja QBE General Insurance Company Limited.
I hereby declare that Mr./Mrs./Ms. has been referred by me needs to be

directly assigned to Raheja QBE General Insurance Company Limited office In my team.
RM Name Employee Code
ASM Name RM Name
Branch Branch
Signature Signature
Date Date
CHECKLIST OF DOCUMENTS TO BE ATTACHED TO THIS FORM
Documents to be submitted by Prospective Agent...Original copy should be presented for verification at the time of submission
of this form.
1. Age Proof : Passport / Birth Certificate / Driving License / PAN Card

2. Address Proof: Passport / Ration Card / Driving License / Electricity Bill / Telephone Bill
3. NOC for Address Proof : (Only in case the address is not in Self Name - Restricted to Spouse and Father only)
4. Educational Proof: ; minimum Std. XI Pass (Marksheet/relevant board/university certificate)
5. Pan Card Copy
6. Photographs 2
7. Agency Agreement
8. Copy of Current insurer cessation certificate - For transfer case
9. Cancel cheque copy - for NEFT transfer

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Agent Application Form

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Agent Application Form

Application Type : New Transfer URN NO :

Channel Type : Agency Motor

Branch Name: Branch code:

Raheja QBE General Insurance Limited.

5) Date of birth (DD/MM/YYYY) Attach age proof :

6) Education qualifications. (Tick the right box)

Name of the examination body

*please attach agency cessation letter issued by the insurer

10) Details of other insurance related activities undertaken, if any:

11. I declare that----

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

Date: Yours faithfully

Notes and instructions

1. The application should be filled in Hindi or English language

1.Gender Male Female

2.Marital Status : Single Married If Married, Anniversary Date :

3.Basic Qualification: Roll NO Board Name

5.GST Number (Optional)

If yes please specify

If yes furnish name & relationship

If yes, please attach the proof.

14.Are you Politically exposed person? Yes No

Training and Examination details

Training mode: online offline Location (city) Institute

Examination mode: online Body: NSEIT Other

Location Language Exam date

Relationship Manger details/signature And Checklist of Documents Submitted

I hereby declare that Mr./Mrs./Ms. has been referred by me needs to be

RM Name Employee Code

ASM Name RM Name

CHECKLIST OF DOCUMENTS TO BE ATTACHED TO THIS FORM

1. Age Proof : Passport / Birth Certificate / Driving License / PAN Card

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