Self-Declaration-IRDA License/URN holders

I do hereby declare that all the following details given by me regarding my agent license are
true and correct to the best of my knowledge, information and belief.

Name of the Insurer*

Agent License /URN Number*
License Status*
License Valid From
License Valid To
Code/ URN Termination Letter
submission Date
*marked field need to be mandatorily filled.

I do herby affirm and state that the above mentioned declarations are true and correct to
the best of my knowledge and is given voluntarily out of my free will and volition, without
any coercion. Please note that I have submitted /will submit the request for termination of
my code to my previous insurer, which I have disclosed above.

I hereby assure that I will submit the NOC to Exide Life Insurance Company Limited
(hereinafter referred to as the “Company”) on or before 120 days from my date of joining.
In case, the above timeline is breached, the Company can take appropriate action against
me which may include immediate termination of my services from the Company.

I further undertake that I will not solicit, canvass or procure insurance business on behalf of
any insurance company other than Exide Life Insurance Company Limited. In case of any
breach on the same, the Company can take appropriate disciplinary or legal action as may
be required by the Company against me which may include immediate termination of my
services from the Company.

I also hereby irrevocably indemnify the Company from all the losses, costs, compensations,
damages, claims, litigations etc. or whatsoever, if any, arising out of any misrepresentations
made by me in this declaration.

Name: Signature: Date:

Permanent Address: ____________________________________________

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