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.
LICENSE & BANK ACCOUNT DETAILS
Guarantor's Address Proof (Submit any one address proof out of the list of acceptable documents) :
Guarantor's ID :
1.Age Proof (Photo ID): Passport Copy, National Driving License, National Identity Card, Voters Registration :
2.Address Proof: Telephone bill/ Electricity bill/ Bank A/c Statement
(Not more than THREE months old), Tenancy agreement, Letter
(on letterhead) from clergy.
3. Education Proof : School/ College/ University degree certificate
4. Passport photograph (White Background):