AGENCY PROFILE APPLICATION FORM

    I hereby declare that particulars given below are true and the APPOINTMENT for which I apply will be used only by myself for soliciting or procuring insurance business for your insurance company. I also declare that –

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

    (2) I have not been found guilty of criminal misappropriation or criminal breach of trust or cheating or forgery or an abetment of or attempt to commit any such offence by a court of competent jurisdiction.

    (3) I have not been found guilty of or to have knowingly participated in or connived at any fraud, act of mis-representation against an insurer or an insured.

    (4) I agree to abide by the rules, regulations and guidelines laid down by NAICOM and your company from time to time.

    OFFFICE USE

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    GUARANTORS DETAILS










    Guarantor 2










    ADVISOR'S DOCUMENTS/ INFORMATION TO BE SUBMITTED: