INSURER REFERENCE NO.

: 65090665

TO
THE DEPARTMENT OF LICENSING
THE INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY.

DEAR SIR,
I request that ---
(a) a certificate to act as a specified person may be granted to me.
(b) my corporate agent's name ICICI BANK LTD license no CA00112 valid till 31/03/2019
(c) my certificate bearing number null and expiry date null may be renewed for a further period of three years.

2 I hereby declare that particulars given below are true and that the certificate for which I apply will be used only by myself for
soliciting procuring insurance business.

(1.) Name : P R I T I K U D A L E

(2.) Father's/Husband Name : V I L A S N I V R U T T I M E H E T R E

(3.) Full Address : K U D A L E W A D I

House No : K U D A L E W A D I

Street : K O L V I H I R E

Town : P U N E

District : P U N E

State : M A H A R A S H T R A

Pincode : 4 1 2 3 0 3

Telephone No.(STD Code -- Number):

(4.) Date of Birth : 1 7 1 0 1 9 9 7

(5) Title: State 1 if are Mr.,2 Mrs., 3 Miss: 3

(6) Please state the Corporate Agents Name,Licence No. and date of Expiry.

(a) Corporate Agent's Name : I C I C I B A N K L T D

(b) Corporate Agent's Address : I C I C I B A N K T O W E R S , B A N D R A - K U R L

(c) Corporate Agent's Licence No : C A 0 0 1 1 2

(d) Date of Expiry : 3 1 0 3 2 0 1 9

(7) If you are an applicant from a rural place,state 1, in the box :

(8) Educational Qualification :OTHERS
(9) Give Particulars of pass in pre-recruitment test conducted by the examination body nominated by the IRDA :

(a) Name of Examination body : N S E . I T

(b) Candidate's Number :

(c) Center Of Examination : N S E I T L I M I T E D - B A N G A L O R E

(d) Date of Passing : D D MMY Y Y Y

(10) Give Particulars of Practical Training completed from an approved institution :

(a) Training Hours Completed :

(b) Name of Training Institute :

(c) Candidate's Number :

(d) Center (Place) Of Training :

(e) Starting Date of Training: D D MMY Y Y Y

3. I further declare that _____________________________________________________________________________________________

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

(b) I have not been found guilty of criminal misappropriate 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.
(c) I have not been found guilty of or to have knowingly participated in or connived at any fraud, dioshonesty, or misrepresentation against
an insurer or insured in the course of any judicial proceeding relating to any policy of insurance or the winding up of an insurance company
or in the course of an investigation of the affairs of an insurer, and I have not violated the code of conduct specified under Regulation 9 of
Insurance Regulatory and Development Authority(Licensing of corporate Agents) Regulations, 2002.

4. I have made the payment of certificate fee of rupees five hundred and for which I enclose the documentry evidence.
5. I enclose the following documents in support of the educational qualification, pre-recruitment test, and the practical traininig.

(a) _________________________________________________ (b) ________________________________________

Place Your Faithfully,

Date

(x) (Signature of Applicant) (Signature should not go outside box)

Notes and Instructions

1. An Individual can apply for only a certificate which will entitle him to solicit or procure insurance business of any class and to act as the
specified person of a corporate agent for one life insurer,one general insurer,or both.
2. The application should be filled in, as far as possible, either in Hindi or English.
3. Any correction or alternation made in any answer to the questions in the application should be initiated by the applicant.
4. An applicant must be atleast 18 years of age on the date of the application. If required the applicant shall furnish proof of age.
5. An applicant shall furnish the proof of educational qualification, pass in the pre-recruitment test conducted by the examination body
nominated by Insurance Regulatory and Development Authority, and completion of practical traininig from a traininig institution approved
by the Insurance Regulatory and Development Authority, along with the application.
6. The fees payable by an applicant is rupees five hundred.
7. An application for renewal should reach the designated person through the corporate agent before the expiry of license held by the
applicant but not more than three months before such expiry. If the application does not reach the designated person at least 30 days before
the date on which the last license ceases to be in force, an additional fee of one hundred rupees should be payable. In this connection please
refer to the provisions of subsections(3) and (3A) of section 42D of the Insurance Act, 1938
 Fit & Proper / Annexure 1
INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA
(REGISTRATION OF CORPORATE AGENTS)REGULATIONS, 2015

Declaration and Undertaking of Principal Officer / Director / Managing Partners (A Separate form needs to be signed by each

individuals)

Que No Question Yes/No Remarks

1 Have you ever registered or obtained license from any of the regulatory authorities under N NA
any law such as SEBI, RBI, IRDA, PFRDA, FMC etc. ?
2 Have you carried on business under any name other than the name stated in this N NA
application?
3 Have you been ever refused or restricted by any regulatory authority to carry on any N NA
business, trade or any profession for which a specific license registration or other
authorization is required by law?
4 Have you been ever censured or disciplined or suspended or refused permission or license N NA
or registration by any regulatory authority to carry on any business activity?
5 Have you been subject to any investigations or disciplinary proceedings or have been N NA
issued warning or reprimand by any regulatory authority?
6 Have you been convicted of any offence or subject to any pending proceedings under any N NA
law?
7 Have you been banned from entry from any profession / occupation at any time? N NA
8 Details of prosecution if any, pending or commenced or resulting in conviction in the past N NA
for violation of economic laws and regulations?
9 Details of criminal prosecution if any, pending or commenced or resulting in conviction in N NA
the past against the applicant?
10 Do you attract any of the disqualifications envisaged under Section 164 of the companies N NA
Act, 2013. ?
11 Have you been subject to any investigation at the instance of Government / Department or N NA
Agency ?
12 Have you at any time been found guilty of violation of rules / regulations / legislative N NA
requirements by customs / excise / income tax / foreign exchange / other revenue
authorities? If so give particulars.
13 Have you at any time come to the adverse notice of a regulator like SEBI, IRDA , PFRDA N NA
(Reversal / setting aside is on technical reasons like limitation or lack of jurisdiction, etc.
and not on merit. If the order of the regulator is temporarily stayed and the appellate /
court proceedings are pending, the same also should be mentioned)
14 Has any of your group company / associate company / related party been carrying any N NA
license issued by the IRDA?
15 Any other explanation / information in regard to items I and II and other information N NA
considered relevant for judging fit and proper criteria of the applicant ?

Undertaking

I confirm that the above information is to the best of my knowledge and belief, true and complete. I undertake to keep the

Authority fully informed,as soon as possible, of all events, which take place subsequently to my appointment which are relevant

to the information provided above.

Signature:

Name:

Designation:

Date:

Place: