EMPANELMENT OF HOME LOAN AGENT lHLA) APPLICA TION FORM Affix Passport sizephoto and sIgnacross 1.

Nameof the LIC Agent 2. Dateof Birth 3. Residential Address 4. Qualifications 5. AgencyCodeNo./Branch . (Club Memberinformation) 6. Communication Address 7. Telephone Nos. Mobile Nos. 8. No. of yearsin the Business: 9. Do you havean Office If yes,No. of Employees Roll: on 10. No. of Clientsin your database: a. Individual Clients b. Corporate Clients (give list separately) 11. Detailsof pastexperience retail marketing in [HousingLoans,Personal Loans,Credit Cards,Others(specify)] a. Nameof the InstituionlBank/Others b. Natureof Productmarketed c. Periodof suchwork undertaken d. No. of Cases/Accounts procured e. Quantumof business (Amt. involved) . f. Whetherthe activity is continuing. 12.No. of clientsyou intendto contactin 1 year 13.Estimated of clientsyou expectto introducein 1 year No. 14.Give your brief Business Plan/Strategy marketinghousingloans for (attachseparate sheet, necessary) if 15.Any otherinformation. Place: Sign of the AgentIName Date: LIC Branch Manager's Certification It is certified that the aboveinformation (1) to (8) aboveare correct as per our recordsand the applicant'sAgency for procuringLIC Policies is in force. The signatureof the Agent affixed below is herebyattested. (proofsto be enclosed)

Name/Signatureof Agent.