A non-official member shall be entitled to a fee for attending meetings of the Committee of Rs 100 for each day of the meeting.]
SCHEDULES
SCHEDULE I
Form I
(See Rule 5)
RESERVE BANK OF INDIA
To
The Manager,
Reserve Bank of India
. . . . . . . . . . . . . . . . . . . .London20.
This is to inform you that the. . . . . . . . . . . . . . have this day deposited the undermentioned securities.
Manager,
| Number |
Loan |
Face Value in sterling) |
Market-value (ex-dividend in sterling) |
Interest of dividend paid up to |
Remarks |
| |
|
|
|
|
|
| Total |
|
|
|
|
|
Form II
(See Rule 5)
RESERVE BANK OF INDIA
Securities Department
LT.
No.
ST
. . . . . . . 20 .
Certified that the. . . . . . . . . . . . . . . . . . . . . have made the undernoted deposits in terms of the Insurance Act, 1938.
Manager.
| |
Cash |
|
Approved Securities |
Remarks |
| |
Loan |
Face Value |
Market Value |
| 1 |
2 |
3 |
4 |
5 |
6 |
| |
|
|
|
|
|
| Total |
|
|
|
|
|
Grand Total of Columns 2 and 5 Rs . . . . . . . . . . . . . . .
Form III
(See Rule 5)
No. . . . . . . . . . . . . S.
RESERVE BANK OF INDIA
Securities Department
. . . . . . . . . . 20 .
Statement showing the particulars of deposits held on behalf of the . . . . . . . . under Section. . . . . . . . . . . . of the Insurance Act, 1938.
| Loan |
Existing Deposits (excluding deposits withdrawn) |
New Deposits Received on |
Total |
Sterling deposits have converted at ls. 6 d. |
| Face Value |
Book Value |
Face Value |
Book Value |
Face Value |
Book Value |
| Total |
|
|
|
|
|
|
| Securities |
|
| Cash |
|
|
|
|
|
|
| GRAND TOTAL |
|
|
|
|
|
|
Certified that the above agrees with the entries in the books maintained by the Bank.
To
The Controller of Insurance, Simla.
Manager.
Form IV
(See Rule 10)
List of deposits under the Insurance Act, 1938 held in the custody of the Reserve Bank of India on the 31st December, 20 .
| Name of Depositor |
Loan or nature of deposits |
Amount |
Total face value |
Cash |
Total Book Value of Securities and cash |
| |
|
|
|
|
|
Form IV-A
[See Rule No. 10(c)(1)]
Return of investments of the Controlled Fund of the . . . . . . . . . . . . . . . . . Insurance. . . . . . . . Company Limited . . . . . as at . . . . . 20.
[See Section 28-A(1)]
(Please see the note appended to the form)
PART A
Investment approved under Section 27-A(1) of the Insurance Act.
(1) Government securities and other securities charged on the revenues of the Central Government or of the Government of a Part A State or guaranteed fully as regards principal and interest by the Central Government or the Government of any Part A State and securities issued or guaranteed fully as regards principal and interest by the Government of a Part B State and specified as approved securities by the Central Government.
| Full description of the security |
Date of Purchase |
Date of Maturity |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(2) Approved securities other than those referred to in item (1) above
[See Section 2(3)]
| Full description of the security |
Date of Purchase |
Date of Maturity |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(3) Securities guaranteed fully as regards principal and interest by a Provincial Government in Pakistan or charged on the revenues of any part of that Dominion and debentures of other securities for money issued by or on behalf of the Port of Karachi and satisfying the requirements of Rule 10-A of the Insurance Rules.
| Full description of the security |
Date of Purchase |
Date of Maturity |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(4) Securities issued by the Government of any country outside India.
| Full description of the security indicating the name of the country |
Date of Purchase |
Date of Maturity |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(5) Debentures or other securities for money issued with the permission of the State Government by any Municipality in a State.
[See Section 27-A(1)(c)]
| Full description of the debenture or security |
Date of Purchase |
Date of Maturity |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(6) Debentures or other securities for money issued by any authority constituted under any housing or building scheme approved by the Central Government or a State Government or by any authority or body constituted by any Central Act or Act of a State Legislature.
[See Section 27-A(1)(d)]
| Name of the housing or building scheme |
Name of the Government approving the scheme or the Act under which the scheme is constituted |
Date of investment |
Maturity date of the debentures of security |
Rate of Interest |
Face Value Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(7) First Mortgages on immovable property situated in India under any housing or building scheme of the insurer approved by the Central or a State Government.
[See Section 27-A(1)(e)]
| |
Amount outstanding |
| Location of the property |
Value of the property (date of last valuation of the property) |
Amount advanced |
Date of advance |
Rate of Interest |
Name of the State approving the scheme and date of approval |
Principal |
Interest* |
Remarks |
| |
|
|
|
|
|
|
|
|
*To be stated if outstanding for more than one year.
(8) Debentures secured by a first charge on any immovable property, plant or equipment, of any company which has paid interest in full for five years immediately preceding or for at least five out of the six or seven years immediately preceding on such or similar debentures issued by the company.
[See Section 27-A(1)(f)]
| Name of the Company |
Date of issue of debentures |
Date of Purchase by the insurer |
Whether the charge is on property, plant or equipment or equipment |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
|
(9) Debentures secured by a first charge on any immovable property, plant or equipment of any company where, either the book value or the market value, whichever is less, of such property, plant or equipment is more than three times the value of the debentures.
[See Section 27-A(1)(g)]
| Name of the company |
Date of Purchase |
Date of Maturity of the debentures |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(10) First Debentures secured by a floating charge on all the assets of any Company which has paid dividends on its ordinary shares for the five years immediately preceding or for at least five years out of six or seven years immediately preceding.
[See Section 27-A(1)(h)]
| Name of the company |
Date of Purchase by the insurer |
Date of Maturity of the debentures |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(11) Preference shares of any company which has paid dividends on its ordinary shares for the five years immediately preceding or for at least five out of the six or seven years immediately preceding.
[See Section 27-A(1)(i)]
| Name of the company |
Date of purchase by the insurer |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
(12) Preference shares of any company on which dividends have been paid for the five years immediately preceding or for at least five out of six or seven years immediately preceding and which have priority in payment over all the ordinary shares of the company in winding up.
[See Section 27-A(1)(j)]
| Name of the company |
Date of purchase |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
(13) Shares of any company guaranteed by another company such other company having paid dividends on its ordinary shares for the five years immediately preceding or for at least five out of the six or seven years immediately preceding.
[See Section 27-A(1)(k)]
| Name of the company |
Date of the guaranteeing company |
Date of Purchase |
Face Value |
Book Value |
Market Value |
Whether proviso to S. 27-A(1)(k) complied with |
Remarks |
| |
|
|
|
|
|
|
|
(14) Shares of the company on which dividends of not less than four per cent including bonus have been paid for seven years immediately preceding or for at least seven out of the eight or nine years immediately preceding.
[See Section 27-A(1)(l)]
| Name of the Company |
Date of Purchase |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
(15) First Mortgages on immovable property situated in the States or in any country where the insurance is transacting insurance business.
[See Section 27-A(1)(m)]
| Situation of the property and name of the owner |
Whether land or buildings or both |
Whether land is leasehold or freehold |
Outstanding period of the mortgage if property is lease-hold |
Outstanding period of the lease, if the property is leasehold |
Type of mortgage |
Date of mortgage |
Value of the land |
| |
|
|
|
|
|
| Value of the Buildings |
Date of last valuation of the property and nature of the Valuer |
Amount advanced on the Mortage |
Rate of Inte-rest |
Outstanding amount |
Remarks |
| Land |
Buildings |
Principal |
Intrest |
| |
|
|
|
|
|
|
(16) Immovable Property situated in the States or in any country where the Insurer is transacting insurance business.
[See Section 27-A(1)(n)]
| Situation of the property |
Land or Building or both |
Whether land is leasehold or freehold |
Date of Purchase |
Amount invested by the insurer |
Net Annual Rental Value of the property, i.e., net of taxes, maintenance, depreciation, etc. |
Whether free from all encumbrances |
Remarks |
(17) Loans on life insurance policies within their surrender value issued by the insurer or by another insurer whose business he has taken over and in respect of which business he has assumed liability.
[See Section 27-A(1)(o)]
| Amount of Loan outstanding on the date |
Advance under automatic Non-forfeiture scheme of the insurer |
Remarks |
| |
|
|
(18) Life interests and Loans on Life interests.
[See Section 27-A(1)(o) and (p)]
| Date of purchase or grant of loan on life interest |
Value of the Life Interest |
Purchase price or Amount of Loan |
Whether the transaction is covered by any life policy |
Whether the Value is certified by an actuary |
Remarks |
| |
|
|
|
|
|
(19) Fixed deposits with Banks included in the Second Schedule to the Reserve Bank of India Act, 1934, or Co-operative Societies registered under the Indian Co-operative Societies Act, 1912, or any other law for the time being in force the primary object of which is to finance Co-operative Societies similarly registered.
[See Section 27-A(1)(q)]
| Name of the Bank or Co-operative Society with addresses |
Date of Deposit |
Rate of Interest |
Period of deposit |
Amount of deposit |
Whether Section 27-A(9) satisfied |
Whether proviso to Section 27-A (9) attracted |
Remarks |
| |
(20) Shares and Debentures of Co-operative Societies registered under the Indian Co-operative Societies Act, 1912, or any other law for the time being in force.
[See Section 27-A(1)(r)]
| |
SHARES |
DEBENTURES |
|
| |
.png) |
.png) |
| |
Face Value |
Book Value |
Market Value |
Face Value |
Book Value |
Market Value |
| Name and address of Society |
Date of Purchase |
Date of Maturity of Debentures |
|
|
|
|
|
|
Remarks |
| |
|
|
|
|
|
|
|
|
|
(21) Other investments notified under clause (s) of sub-section (1) of Section 27-A.
| Description of the investment |
Date of purchase |
Face Value |
Book Value |
Market Value |
Interest or dividend paid last |
Remarks |
| |
|
|
|
|
|
|
PART B
Relating to investments held invested under Section 27-A(2) of the Insurance Act in respect of which a resolution has been adopted in terms of that section
| |
Rs |
| (1) 15 per cent of the sum referred to in sub-section (1) of Section 27 of the Insurance Act estimated as at the date of this return. |
|
(2) Particulars of investments.
| Name of the company whose shares or debentures are held by the insurer and description of investments |
Date of Purchase |
Date of Maturity |
Face Value |
Book Value |
Market Value |
Name of Directors of the insurer interested in the investment |
Extent of interest of Directors |
Whether Section 27-A(3), (4) and (5) satisfied |
Remarks |
| |
|
|
|
|
|
|
|
|
|
| Total |
|
|
|
|
|
|
|
|
|
PART C
Particulars of investments other than those shown in Part A, Part B and Part D and not satisfying the requirements of sub-sections (1) and (2) but complying with the requirements of sub-sections (3) and (4) of Section 27-A
| Full description of the investment (including the name of the Company) |
Date of investment |
Face Value |
Book Value |
Market Value |
Names of the Directors of the Insurer interested in the investment |
Extent of interest of Directors |
Remarks |
| |
|
|
|
|
|
|
|
I
Particulars of investments not satisfying the requirements of sub-sections (3) and (4) of Section 27-A
| |
Amount held invested in excess of the requirements of |
|
| .png) |
| Sub-section (3) |
Sub-section (4) |
| .png) |
.png) |
| Full description of the Investment (including the name of the company in which invested) |
Total value of the Investment |
Clause (a) |
Clause (b) |
Clause (a) |
Clause (b) |
Date of Investment |
Names of the Directors of the insurer who are interested in the investment |
Extent of each Director's interest in the Company |
If the investment is shown in Part A or Part B of the statement indicate it by cross reference |
Remarks |
| |
|
|
|
|
|
|
|
|
|
|
II
Particulars of investments not satisfying the requirements of sub-section (5) of Section 27-A
| Name of the Company |
Date of investment |
Face Value |
Book Value |
Market Value |
Names of Directors of Insurer interested in the private Company |
Extent of Directors' interest |
Remarks |
| |
|
|
|
|
|
|
|
I hereby certify that the particulars furnished in the return are true and complete to my knowledge.
Date:
Principal Officer.
NOTES TO FORM IV-A
I. (a) Market value of securities, debentures, shares, etc., should be ascertained from published quotations. Where published quotations are not available, it should be stated in the remarks column how the market values have been arrived at.
(b) If accrued interest has been added to the market value it should be stated in the remarks column.
(c) In the case of shares and debentures of Companies, the location of the Companies should also be stated.
[(d) In the case of mortgages of property and properties owned by the insurer, location of each property should be separately stated.
(e) In case of investments made on and after the 19th January, 1950, the date of purchase should be given.
II. In respect of investments in Part A of the statement, investments which were approved at the time of the last statement but ceased to be so subsequently should be distinctly marked by double asterisks.
III. Investment held in deposit under Section 7 or 98 of the Act should also be included in the return.]
65[Form IV-AA
[See Rule 10-C(3)]
Return of investments of the assets of the (insurer) as at 20[See Section 28-B(1) of the Act].
(Please see the notes appended to the form)
PART A
Investments approved under Section 27-B(1) of the Insurance Act, 1938
(1) Government securities and other securities charged on the revenues of the Central Government or of a State Government or guaranteed fully as regards principal and interest by the Central Government or a State Government and specified as approved securities by the Central Government.
| Full description of the security |
Date of Purchase |
Date of Maturity |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(2) Approved securities other than those referred to in item (1) above
[See Section 2(3) of the Act]
| Full description of the security |
Date of Purchase |
Date of Maturity |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(3) Securities issued by the Government of any country outside India.
| Full description of the security indicating the name of the country |
Date of Purchase |
Date of Maturity |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(4) Debentures or other securities for money issued with the permission of the State Government by any Municipality in a State.
[See Section 27-B(1)(a) of the Act]
| Full description of the Debenture or security |
Date of Purchase |
Date of Maturity |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(5) Debentures or other securities for money issued by any authority constituted under any housing scheme approved by the Central Government or a State Government or by any authority or body constituted by any Central Act or Act of a Legislature.
[See Section 27-B(1)(a) of the Act]
| Name of the housing or building Scheme |
Name of the Govt. approving the Scheme or the Act under which the scheme is Constituted |
Date of investment |
Maturity date of Debentures or security |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
|
(6) First Mortgages on Immovable Property situated in India under any housing or building Scheme of the insurer approved by the Central or a State Government.
[See Section 27-B(1)(a) of the Act]
| |
|
|
|
|
|
Amount outstanding Principal Interest* |
|
| Location of the property |
Value of the property (date of last valuation of property) |
Amount Advanced |
Date of Advance |
Rate of Interest |
Name of the State approving the scheme and date of approval |
Remarks |
| |
|
|
|
|
|
|
|
*If outstanding for more than one year the fact should also be stated.
(7) Immovable Property situated in India or in any country where the Insurer is carrying on insurance business.
[See Section 27-B(1)(a) of the Act]
| Situation of the property |
Land or Building or both |
Whether land is leasehold or free-hold |
Date of Purchase |
Amount invested by the insurer |
Net Annual Rental value of the property, i.e., net of taxes maintenance, depreciation, etc. |
Whether free from all encumbrances |
Remarks |
| |
|
|
|
|
|
|
|
(8) Fixed deposits with Banks included in the Second Schedule to the Reserve Bank of India Act, 1934, or co-operative societies registered under the Co-operative Societies Act, 1912, or any other law for the time being in force the primary object of which is to finance co-operative societies similarly registered.
[See Section 27-B(1)(a) of the Act]
| Name of the Bank or Co-operative society with addresses |
Date of Deposit |
Rate of Interest |
Period of Deposit |
Amount of Deposit |
Whether Section 27-B(10) satisfied |
Remarks |
| |
|
|
|
|
|
|
(9) Debentures and Shares of Co-operative Societies registered under the Co-operative Societies Act, 1912, or any other law for the time being in force.
[See Section 27-B(1)(a) of the Act]
| |
|
|
Debentures |
Shares |
|
| |
|
|
Face Value |
Book Value |
Market Value |
Face Value |
Book Value |
Market Value |
|
| Name and address of Society |
Date of Purchase |
Date of maturity of Debentures |
Remarks |
| |
|
|
|
|
|
|
|
|
|
(10) Debentures secured by a first charge on any immovable property, plant or equipment, of any company which has paid interest in full for three years immediately preceding or for at least three out of four or five years immediately preceding on such or similar debentures issued by the company.
[See Section 27-B(1)(b) of the Act]
| Name of the Company |
Date of issue of debentures |
Date of purchase by the insurer |
Whether the charge is on property, plant or equipment |
Rate of interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
|
(11) Debentures secured by a first charge on any immovable property, plant or equipment of any company where, either the book value or the market value, whichever is less, of such property, plant or equipment is more than twice the value of the debentures.
[See Section 27-B(1)(c) of the Act]
| Name of the Company |
Date of purchase |
Date of Maturity of the debentures |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(12) First debentures secured by a floating charge on all its assets or by a fixed charge on fixed assets and floating charge on all other assets of any company which has paid dividends on its equity shares for the three years immediately preceding or for at least three out of the four or five years immediately preceding the date of the investment.
[See Section 27-B(1)(d) of the Act]
| Name of the Company |
Date of purchase by the Insurer |
Date of Maturity Debentures |
Rate of Interest |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(13) Preference shares of any company which has paid dividends on its equity shares for the three years immediately preceding or for at least three out of four or five years immediately preceding.
[See Section 27-B(1)(e) of the Act]
| Name of the Company |
Date of purchase by the Insurer |
Rate of Interest |
Whether redeem-able and if so date of redemption |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(14) Preference shares of any company on which dividends have been paid for three years immediately preceding or for at least three out of four or five years immediately preceding and which have priority in payment over all the equity shares of the company in winding up.
[See Section 27-B(1)(f) of the Act]
| Name of the Company |
Date of purchase |
Rate of Interest |
Whether redeem-able and if so date of redemption |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
|
|
(15) Shares of any company which have been guaranteed by another company such other company having paid dividends on its equity shares for the three years immediately preceding or for at least three out of the four or five years immediately preceding.
[See Section 27-B(1)(g) of the Act]
| Name of the Company |
Name of the guaranteeing Company |
Date of purchase |
Face Value |
Book Value |
Market Value |
Whether proviso to Section 27-B (1)(g) complied with |
Remarks |
| |
|
|
|
|
|
|
|
(16) Shares of any company on which dividends of not less than four per cent including bonus have been paid for the three years immediately preceding or for at least three out of the four or five years immediately preceding.
[See Section 27-B(1)(h) of the Act]
| Name of the company |
Date of purchase |
Face Value |
Book Value |
Market Value |
Remarks |
| |
|
|
|
|
|
(17) First Mortgages on immovable property situated in India or in any other country where the insurer is carrying on insurance business.
[See Section 27-B(1)(i) of the Act]
| Situation of the property and name of the owner |
Whether land or buildings or both |
Whether land is leasehold or free-hold |
Outstanding period of the mortgage if property is lease-hold |
Outstanding period/term of the lease, if the property is leasehold |
Type of mortgage |
Date of mortgage |
Value of the land |
| |
|
|
|
|
|
|
|
| |
|
Amount advancedon the Mortgage |
|
Outstanding amount |
|
| Value of the Buildings |
Date of last valuation of the property and name of the Valuer |
Land |
Buildings |
Rate of Interest |
Principal |
Interest |
Remarks |
| |
|
|
|
|
|
|
|
(18) Other investments notified under clause (j) of sub-section (1) of Section 27-B of the Act.
| Description of the investment |
Date of Purchase |
Face Value |
Book Value |
Market Value |
Interest or dividend paid last |
Remarks |
| |
|
|
|
|
|
|
PART B
Relating to investments held invested under Section 27-B(3) of theInsurance Act, 1938 in respect of which a resolution has beenadopted in terms of that section
(1) 25 per cent of the assets referred to in sub-section (3) of Section 27-B of the Act estimated as at the date of this return.
(2) Particulars of investments.
| Name of the Company whose shares or debentures are held by the insurer and description of investments |
Date of Purchase |
Date of Maturity |
Face Value |
Book Value |
Market Value |
Name of Directors of the insurer interested in the investment |
Extent of interest of Directors |
Whether Section 27-B(4), (5) and (6) satisfied |
Remarks |
| |
|
|
|
|
|
|
|
|
|
| Total |
|
|
|
|
|
|
|
|
|
PART C
Particulars of investment other than those shown in Part A, Part B andPart D and not satisfying the requirements of sub-sections (1) and (3) but complying with the requirements of sub-sections (4) and (5) of Section 27-B of the Act
| Full description of the investment (including the name of the Co.) |
Date of investment |
Face Value |
Book Value |
Market Value |
Name of the Directors of the Insurer interested in the Investment |
Extent of interest of Director's |
Remarks |
| |
|
|
|
|
|
|
|
PART D
I
Particulars of investments not satisfying the requirements ofsub-sections (4) and (5) of Section 27-B of the Act
| |
Amount held invested in excess of the requirements of |
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Sub-section (4) |
Sub-Section (5) |
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| Full description of the Investment (including the name of the company in which invested) |
Total value of the Investment |
Clause (a) |
Clause (b) |
Clause (a) |
Clause (b) |
Date of Investment |
Name of the Directors of the insurer who are interested in the investment |
Extent of each Director's interest in the Company |
If the investment is shown in Part A or Part B of the statement indicate it by cross reference |
Remarks |
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II
Particulars of investments not satisfying the requirements ofsub-section (6) of Section 27-B of the Act
| Name of the company |
Date of investment |
Face Value |
Book Value |
Market Value |
Name of Directors of Insurer interested in the Private Company |
Extent of Director's interest |
Remarks |
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I hereby certify that the particulars furnished in the return are true and complete to my knowledge.
Date:
Principal Officer.
Notes
I. (a) Market value of securities, debentures, shares, etc. should be ascertained from published quotations. Where published quotations are not available, it should be stated in the remarks column how the market values have been arrived at.
(b) If accrued interest has been added to the market value, it should be so stated in the remarks column.
(c) In the case of shares and debentures of Companies, the location of the Companies should also be stated.
(d) In the case of mortgages of property, and properties owned by the insurer, location of each property should be separately stated.
(e) In the case of investments made on and after the 31st December, 1968, the date of purchase should be given.
II. In respect of investments in Part A of the statement, investments which were approved at the time of the last statement, but ceased to be so subsequently should be distinctly marked by double asterisks.
III. Investments held in deposit under Section 7 of the Act should also be included in the return.
66[Form IV-AAA
[See Rule 10-C(I)]
Return of investment of the Controlled Fund of the Life Insurance Corporation of India as at 20 . . . .
[See Section 28-A(1)]
(Please see the Notes appended to the Form)
PART A
(1) Government securities and other securities charged on the revenues of the Central Government or of the Government of a State or guaranteed fully as regards principal and interest by the Central Government or the Government of any State.
| Category of the investment |
Total Face Value |
Total Book Value |
Remarks |
| (a) Government Securities (b) Approved Securities |
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(2) Approved securities other than those referred to in item (1) above.
[See Section 2(3)]
| Category of the investment |
Total Face Value |
Total Book Value |
Remarks |
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(3) Debentures or other securities for money issued with the permission of the State Government by the Municipality in a State.
| Category of the investment |
Total Face Value |
Total Book Value |
Remarks |
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(4) Debentures secured by a first charge on any immovable property, plant or equipment of any company which has paid interest in full for the five years immediately preceding or for at least five years out of the six or seven years immediately preceding on such or similar debentures issued by it.
| Total Face Value |
Total Book Value |
Remarks |
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(5)(a) Debentures secured by a first charge on any immovable property, plant or equipment of any company where, either the book value or the market value, whichever is less, of such property, plant or equipment is more than three times the value of such debentures.
| Total Face Value |
Total Book Value |
Remarks |
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(b) Debentures convertible into shares of a company which has paid on its shares dividends of not less than four per cent including bonus for the five years immediately preceding or for at least five years out of the seven years immediately preceding.
| Total Face Value |
Total Book Value |
Remarks |
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(6) Cumulative Preference Shares of any company which has paid dividends on its equity shares for the five years immediately preceding or for at least five years out of the six or seven years immediately preceding, provided such preference shares have priority in payment over all the equity shares of the company in winding up.
| Total Face Value |
Total Book Value |
Remarks |
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(7) Cumulative Preference Shares of any company on which dividends have been paid for the five years immediately preceding or for at least five years out of the six or seven years immediately preceding and which have priority in payment over all the equity shares of the company in winding up.
| Total Face Value |
Total Book Value |
Remarks |
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(8) Shares of any company which have been guaranteed by another company, such other company having paid dividends on its equity shares for the five years immediately preceding or for at least five years out of the six or seven years immediately preceding in each case.
| Category of the investment |
Total Face Value |
Total Book Value |
Whether the total amount of shares of all the companies under guarantee by the guaranteeing company is not in excess of 50% of the paid-up amount of preference and equity shares of the guaranteeing company. |
If the investment including the uncalled liability, if partly paid-up, in the equity shares of any one company, other than the subsidiaries of the Corporation, is in excess of thirty per cent of the subscribed equity share capital of the company, has the prior permission of the Central Govern-ment been obtained? |
Remarks |
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(a) Preference Shares (b) Equity Shares |
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(9) Shares of any company on which dividends of not less than four per cent including bonus have been paid for the five years immediately preceding or for at least five years out of the seven years immediately preceding.
| Category of the investment |
Total Face Value |
Total Book Value |
If the investment, including the uncalled liability, if partly paid-up in the equity shares of any one company, other than the subsidiaries of the Corporation, is in excess of thirty per cent of the subscribed equity share capital of the company has the prior permission of the Central Government been obtained? |
Remarks |
| (a) Preference Shares (b) Equity Shares |
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(10) Immovable property situated in India or in any other country where the Corporation is carrying on insurance business.
| Total amount invested by the Corporation |
Whether free from all encumbrances |
Remarks |
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(11) First Mortgages on immovable property situated in India or in any other country where the Corporation is carrying on insurance business.
| Whether the property mortgaged is not leasehold property with an outstanding term of less than thirty years and whether the mortgage money does not exceed fifty per cent of the value of the property. |
Total outstanding amount |
Remarks |
| Principal |
Interest |
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(12) Loans to any authority or any co-operative society registered under the Co-operative Societies Act, 1912, or under any other law for the time being in force, operating a housing or building scheme in India in any case where the repayment of principal and interest is guaranteed by the Central Government or a State Government.
| Total amount of loans granted |
Total outstanding amount of Principal |
Remarks |
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(13) First mortgages on immovable property situated in India under any housing or building scheme of a public limited company or an establishment in public sector or a co-operative society registered under the Co-operative Societies Act, 1912, or under any other law for the time being in force.
| Category of the Mortgage Loan Scheme |
Whether the mortgage money does not exceed three-fourths of the value of the property |
Total outstanding amount |
Remarks |
| Principal |
Interest |
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(14) Loans on first mortgages of immovable property under any housing or building scheme of the Corporation for the benefit of the policy holders.
| Whether the amount of the loan does not exceed 85% of the value of the property |
Total outstanding amount |
Remarks |
| Principal |
Interest |
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(15) Loans on life interests.
| Amount of Loans Advanced |
Total outstanding amount of principal |
Whether value of life interest certified by an actuary in all cases |
Remarks |
(16) Loans on policies of life insurance within their surrender values issued by the Corporation or by an insurer, the assets and liabilities of whose controlled business have been transferred to and vested in the Corporation or loans to employees of the Corporation for the purpose of purchasing or constructing houses or for the purpose of purchasing motorcycles, motor cars or any other conveyances in accordance with any scheme approved by the Corporation.
| Category of the loan |
Total outstanding amount of Principal |
Remarks |
| (a) Loans on life insurance policies other than advances under Automatic Non-forfeiture (b) Advances under Automatic Non-forfeiture *(c) Loans to employees of the Corporation for the purpose of purchasing or constructing houses (d) Loans to employees of the Corporation for the purpose of purchasing motor cycles, motor cars or any other conveyances. |
*Total outstanding amount of interest also to be shown separately in respect of sub-item (c) |
(17) Life Interest.
| Total value of life interests purchased |
Whether the value is certified by the actuary in all cases |
Remarks |
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(18) Deposits with banks included for the time being in the Second Schedule to the Reserve Bank of India Act, 1934, or with co-operative societies registered under the Co-operative Societies Act, 1912, or under any other law for the time being in force, the primary object of which is to finance other co-operative societies similarly registered.
| Total value of deposits held in banks/co-operative societies, etc. |
Remarks |
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(19) Debentures of, or shares in co-operative societies registered under the Co-operative Societies Act, 1912, or under any other law for the time being in force.
| Category of the investment |
Total Face Value |
Total Book Value |
Remarks |
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| (a) Debentures (b) Shares |
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(20) Other investments as the Central Government may, by notification in the Official Gazette, declare to be approved investments under sub-section (1) of Section 27-A.
| Category of the investment |
Total Face Value |
Total Book Value |
Remarks |
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PART B
Relating to amounts invested or held invested otherwise than in scheduled investments, after securing the unanimous recommendation of the Investment Committee or if no such recommendation can be obtained on a resolution of the Corporation passed by a majority of at least three- fourths of the members present at the meeting
| (1) 15 per cent of the Controlled Fund |
Rs |
(2) Particulars of investments
| Category of the investment |
Total Face Value |
Total Book Value |
If the investment, including the uncalled liability, if partly paid-up in the equity shares of any one company, other than the subsidiaries of the Corporation, is in excess of thirty per cent of the subscribed equity shares capital of the company, has the prior permission of the Central Government been obtained? |
Remarks |
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PART C
Particulars of investments other than those included in Part A, Part B and Part D
| Category of the investment |
Total Face Value |
Total Book Value |
Remarks |
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PART D
I
Particulars of investments made, in the equity shares of any one company, inexcess of thirty per cent of the subscribed equity share capital, includingthe uncalled liability on partly paid-up shares, of the company
| Total Face Value |
Total Book Value |
Amount held invested in excess of the thirty per cent of the subscribed equity share capital of the company including the uncalled liability of partly paid-up shares. |
Whether the investment included in Part A or Part B of the return |
Whether prior permission of the Central Government has been obtained for the investment. |
Remarks |
| Part A |
Part B |
| Face Value |
Book Value |
Face Value |
Book Value |
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II
Particulars of investments made in the shares or debenturesof any private limited company
| Category of the investment |
Total Face Value |
Total Book Value |
Whether the investment included in Part A or Part B of the return |
Whether prior permission of the Central Government has been obtained for the investment. |
Remarks |
| Part A |
Part B |
| Face Value |
Book Value |
Face Value |
Book Value |
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I hereby certify that
(a) the particulars furnished in the return are true and complete to my knowledge;
(b) the various investments have been properly classified in the appropriate Parts of the return;
(c) all the investments conform and have at all times conformed to the provisions of the various relevant sub-sections of Section 27-A of the Insurance Act, 1938, in its application to the Life Insurance Corporation of India; and
(d) prior permission of the Central Government has been obtained in regard to all the investments in private limited companies that have been shown in this return.
Date:
Managing Director
NOTES TO FORM IV-AAA
I. In respect of investments in Part A of the return, particulars of all investments which were scheduled at the time of the last return but ceased to be so subsequently should be given separately.
II. Figures of investments in respect of Capital Redemption (including Annuity Certain) Insurance Business should be given separately.
III. Figures of investments outside India should be given separately.]
Form IV-B
[See Rule 10(c)(2)]
Return showing all the changes that occurred in the investments of the Controlled Fund of . . . . . . . . . . . . . . . . . . . . Insurance Company Ltd., during the quarter ending. . . . . . . . . . . . 20.
[See Section 28-A(2)]
(1) Purchases during the quarter ending 20
| Full description of the investment |
Date of Purchase |
Purchase Price |
Face Value |
Book Value |
Market Value |
State whether the investment complies with Section 27-A(1) |
State whether the additions to the existing holding, if any, would attract Section 27-A(3) or (4) |
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(2) Sales during the quarter ending20.
| Full description of the investment |
Date of Sale |
Sale Price |
Amount raided by the sale |
Face Value of investment Sold |
Book Value of the investment Sold |
Date of Purchase of the investment now Sold* |
Purchase price of the investment now Sold* |
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*To be given in the case of investments made after 19th January, 1950. If made before the said date it may be so stated in the columns. Also see Note 1(a) to 1(d) in Form IV-A.
67[Form IV-BB
[See Rule 10-C(4)]
Return showing all the changes that occurred in the investments of the assets of the . . . . . . . . . . . (insurer), during the quarter ending . . . . . . . . . . . . . . . . . . 20 .
[See Section 28-B(2) of the Act]
(2) Purchases and other additions during the quarter ending, . . . . . . . 20 .
| Full description of the investment |
Date of Purchase or addition |
Purchase Price |
Face Value |
Book Value |
Market Value |
State whether the investment complies with the Section 27-B(1) |
State whether the additions to the existing holding, if any would attract Section 27-B(4) or (5) |
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(2) Sales and other deductions during the quarter ending . . . . . .20 .
| Full description of the investment |
Date of Sale or disposal |
Sale Price |
Amount realised by the Sale |
Face Value of investment sold |
Book Value of the investment sold |
Date of purchase of the investment now sold* |
Purchase price of the investment now sold |
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*To be given in the case of investments made after 31st December, 1968. If made before the said date it may be so stated in the columns. Also see Note 1(a) to 1(d) in Form IV-AA.]
68[Form IV-BBB
[See Rule 10-C(2)]
Return showing all the changes that occurred in the investments of the Controlled Fund of the Life Insurance Corporation of Indiaduring the half year ending . . . .
[See Section 28-A(2)]
(Please see the Notes appended to the Form)
(1) Purchases or additions during the half-year ending20.
| Category of the Investment |
Total Face Value |
Total Book Value |
State whether the additions, together with the existing holding, if any, are |
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If in the equity shares of any one company, more than thirty percent of the subscribed equity share capital of the company (the uncalled liability on partly paid shares to be added) |
In any private limited company, without the prior permission of the Central Govern-ment. |
Remarks |
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(2) Sales or deductions during the half-year ending20
| Category of the investment |
Total Face Value of investment sold or realised |
Total Book Value of the investment sold or realised |
Total amount realised |
Remarks |
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NOTES TO FORM IV-BBB
I. Particulars relating to Scheduled and Non-Scheduled investments should be shown separately.
II. Figures of investments in respect of Capital Redemption (including Annuity Certain) Insurance Business should be given separately.
III. Figures of investments outside India should be given separately.]
Form IV-C
[See Rule 14(7)]
Instrument of proxy
Insurance Company, Limited.
I . . . . . . . . . . . . . . . . . of . . . . . . . . . . . . . . . . . . . . . . . . in the District of . . . . . . . . . . . . . . . . . . . . . . . . . . . . .being a holder of policy/policies bearing the number/numbers . . . . . . . . . . . . . . issued by the . . . . . . . . . . . . . . . . . Insurance Company Limited hereby appoint . . . . . . . . . . . . . . . of . . . . . . . . . . . . . . .who is also a holder of policy/policies bearing the number/numbers . . . . . . . . . . . . . . . issued by the above-mentioned company or in case the said policyholder fails to attend such meeting I appoint . . . . . . . . . . . . . . of . . . . . . . . . . . . . . . . . . who is also a holder of policy/policies bearing the number/numbers . . . . . . . . . . . . . . . issued by the above-mentioned company* as my proxy to vote for me and on my behalf at the meeting of the company to be held for the election of policy holders, directors on the . . . . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . . and at any adjournment thereof.
Signed this . . . . . . . . . . day of . . . . . . . . . . . . . . . . . .
Signature.
Form V
(See Rule 16-A of the Insurance Rules, 1939)
Application for a Licence to Act as an Insurance/Agent
To
The Controller of Insurance,
Simla
Dear Sir,
I request that a licence to act as an insurance agent may be granted to me,
*2. I hereby declare that
(i) I have not been found to be of unsound mind by a court of competent jurisdiction;
(ii) 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; and
(iii) I have not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or misrepresentation against an insurer or an 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
3. I also declare that the particulars given below are true and that the licence for which I hereby apply will be used only by myself for soliciting or procuring insurance business.
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(In block letters) |
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Mr* |
| (1) |
Full name. |
(1) |
Mrs* Miss* |
| (2) |
*Father's/Husband's name. |
(2) |
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| (3) |
Full address. |
(3) |
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| (4) |
Date of birth of the applicant in Christian Era. |
(4) |
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| (5) |
If you ever held a Licence, state No. and date of expiry, otherwise say Nil . |
(5) |
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| (6) |
If the applicant holds a certificate to act as a Principal Agent and/or a Chief Agent and/or a Special Agent, state No. and date of expiry of the certificate or certificates held. If no certificate is held, say Nil. If any such certificate has been applied for, state the date of the application. |
(6) |
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| *Strike out portion not required. |
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Yours faithfully, |
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Government of India Insurance Stamps for Rs 15 |
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| Dated the, 20. |
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Signature of applicant. |
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. A licence can be granted to an individual only and not to a firm or corporate or unincorporate body.
3. An individual can apply for only one licence which will entitle him to solicit or procure insurance business of any class and to act as an insurance agent for any insurer.
4. The application should be filled in, as far as possible, in English language.
5. Any correction or alteration made in any answer to the questions in the application should be initialled by the applicant.
6. An applicant must be at least 18 years of age on the date of submission of the application. In the case of an applicant declaring his age as 18 years, the exact date of birth should be given and in all other cases, either date of birth or failing that the year of birth should be stated against Item 4 of the application. If required the applicant shall furnish proof of age.
7. Payment in cash or by money order, cheque, postal order, postage stamp or Bank draft is not accepted and will be returned at applicant's cost.
8. No acknowledgment of this application will be sent. If one is required, the application should be sent by registered post (acknowledgment due).
Form V-A
(See Rule 16-A of the Insurance Rules, 1939)
Application for Renewal of a Licence to Act as anInsurance Agent
From
Mr.*
(In block letters)
Name of Insurance agentMrs*
Miss*
Full address . . . . . . . . . . .
To
The Controller of Insurance,
Simla.
Licence No._______________Date of expiry____________
Dear Sir,
I request that the above licence may be renewed for a further period of three years.
*2. I declare that since the date of my last application for a licence
(i) I have not been found to be of unsound mind by a court of competent jurisdiction;
(ii) I have not been found guilty of criminal misappropriation or criminal breach of trust of cheating or forgery or an abetment of or attempt to commit any such offence by a court of competent jurisdiction;
(iii) I have not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or misrepresentation against an insurer or an insured in the course of any judicial proceeding relating to any policy of insurance of the winding up of an insurance company or in the course of an investigation of the affairs of an insurer; and
(iv) my licence has not been cancelled at any time by the Controller of Insurance.
| 3*. I hold/have applied for a certificate to act as a |
.png) |
Principal Agent No. P.A._____________expiring on____________ Chief Agent No. C.A._____________expiring on____________ Special Agent No. S.A._____________expiring on____________ |
| 4.* I neither hold nor have applied for a certificate to act as a |
.png) |
Principal Agent Chief Agent Special Agent |
5. I also declare that the facts stated herein are true and that the licence for which I hereby apply will be used only by myself for soliciting or procuring insurance business.
| *Strike out portion not required. |
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Yours faithfully, |
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Government of India Insurance Stamp vide Note 5 |
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| Dated the, 20. |
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Signature of applicant. __________________ |
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. The name and the licence No. given in the application are identical with those shown in the last licence held. If there is any subsequent change in the name, the reasons for the same should be stated furnishing documentary evidence for the same.
3. Any correction or alteration made in the application should be initialled by the applicant.
4. The application should be filled in as far as possible in the English language.
5. The application should reach the Controller of Insurance before the expiry of the last licence held by the applicant but not more than three months before such expiry and Government of India Insurance Stamps for Rs 15 should be affixed to it. If the application does not reach the Controller of Insurance at least 30 days before the date on which the last licence ceases to be in force, Government of India Insurance Stamp to the value of Rs 7 should be affixed to the application by way of penalty. In this connection please also refer to the provisos to Rule 16-A of the Insurance Rules, 1939.
6. Payment in cash or by money order, cheque, postal order, postage stamp or Bank draft is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required, the application should be sent by registered post (acknowledgment due).
Not transferable
Form V-B
Not Transferable Government of India
Office of The Controller of Insurance
Licence NO.___________
(See Rule 16-A of the Insurance Rules, 1939)
Licence to Act as an Insurance Agent under Part IIof the Insurance Act, 1938
To be filledMr.
in by the applicantMrs
in Block Letters Miss
Address______________________________________________
_____________________________________________________
having paid the prescribed fee and having made the necessary declaration is hereby authorised to act as an Insurance Agent for three years fromSimla, dated the,20.
Signature of Licence holder__________________________Controller of Insurance.
This licence is not valid unless it bears a facsimile of the signature of the Controller of Insurance and the initials of a person authorised by him in this behalf and the signature of the licence holder. The latter should put his signature as soon as the licence is received.
Notes
I. If it is desired to renew this licence for a further period, the procedure laid down in Rules 16 and 16-A of the Insurance Rules, 1939, shall be followed, and an application for renewal should reach the Controller of Insurance before the licence expires. In this connection attention is also invited to the provisos to Rule 16-A of the Insurance Rules, 1939.
2. This licence authorises the licence holder to act as an agent for any registered insurer and for any class of insurance business, and therefore no identifying mark or note of any description by which the identity of an insurer might be established should be placed on the licence.
3. No correction in this licence will be valid unless initialled by the Controller of Insurance or a person authorised by him in this behalf.
Form V-P
Application from a Firm or Company for a Licenceto Act as an Insurance Agent
(See Rule 13-A of the Insurance Rules, 1939)
To
The Controller of Insurance,
Simla,
Dear Sir,
It is requested that a licence to act as an INSURANCE AGENT may be granted to our Firm/Company.
2. *It is hereby declared that
(i) any partner of our Firm/any Director of our Company has not been found to be of unsound mind by a court of competent jurisdiction;
(ii) any partner of our Firm/any Director of our Company has 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;
(iii) any partner of our Firm/any Director of our Company has not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or misrepresentation against an insurer or an insured in the course of any judicial proceedings relating to any policy of insurance or the winding up of an insurance company in the course of an investigation of the affairs of an insurer; and
(iv) any partner of our Firm/any Director of our Company is not a minor.
3. *It is also declared that the particulars given below are true and that the licence for which our Firm/Company apply will be used only by our Firm/Company for soliciting or procuring general Insurance business.
| 1, |
Full name of the applicant. (In Block Letters) |
(1) |
Company/Firm. . . . . . . . . . . . . . . . |
| 2. |
Full address. |
(2) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 3. |
(i) (In the case of Firm) the names of all the partners therein; |
(3) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . |
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(ii) In the case of a Company) the name of the Directors. |
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| 4. |
State number and date of expiry of certificate to act as a Principal Agent held immediately before the 1st August, 1957. |
(4) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 5. |
The date from which the licence should be effective. |
(5) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . |
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Government of India Insurance Stamps for Rs 15 |
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Name of place . . . . . . . . . . . . . . . . .
Dated the . . . . . . . . . . . . . . . . . . . . ., 20.
Yours faithfully,
Signature of applicant.
*Strike out portions not required.
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. A licence can be granted to a firm or company registered under Section 42-A of the Act, which held a certificate to act as a Principal Agent immediately before the 1st August, 1957.
3. A firm or company registered under Section 42-A of the Act, which held a certificate to act as a Principal Agent immediately before the 1st August, 1957, can apply for only one licence which will entitle it to solicit or procure any class of general insurance business and to act as an insurance agent for any insurer.
4. The application should be filled in, as far as possible, in the English language.
5. Any correction or alteration made in any answer to the questions in the application should be initialled by the applicant.
6. Payment in CASH OR BY MONEY ORDER, CHEQUE, POSTAL ORDER, POSTAGE STAMP OR BANK DRAFT is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required the application should be sent by registered post (acknowledgment due).
Form V-PA
Application from a Firm or Company for Renewalof a Licence to Act as an Insurance Agent
(See Rule 16-A of the Insurance Rules, 1939)
From
Name of applicant . . . . . . . . . . . . . . . .
(In Block Letters)
Full address . . . . . . . . . . . . . . . . . .
(In Block Letters)
To
The Controller of Insurance,
Simla.
Licence No. . . . . . . . . .
Date of expiry . . . . . . . .
Dear Sir,
It is requested that the above licence may be renewed for a further period of three years.
2. *It is hereby declared that
(i) any partner of our Firm/any Director of our Company has not been found to be of unsound mind by a court of competent jurisdiction;
(ii) any partner of our Firm/any Director of our Company has 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;
(iii) any partner of our Firm/any Director of our Company has not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or misrepresentation against an insurer or an 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
(iv) any partner of our Firm/any Director of our Company is not a minor.
3. *It is also declared that the particulars given above are true and that the licence for which our Firm/Company apply will be used only by our Firm/Company for soliciting or procuring general insurance business.
Yours faithfully,
Signature of applicant.
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|
| |
Government of India Insurance Stamps vide Note 5 |
|
| |
|
|
Dated the . . . . . . . . . . . . . . . . ., 20 .
*Strike out portions not required.
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. The name and the licence number given in the application should be identical with those shown in the last licence held. If there is any subsequent change in the name, the reasons for the same should be stated furnishing documentary evidence for the same.
3. Any correction or alteration made in the application should be initialled by the applicant.
4. The application should be filled in, as far as possible, in the English language.
5. The application should reach the Controller of Insurance before the expiry of the last licence held by the applicant but not more than three months before such expiry and Government of India Insurance stamp for Rs 15 should be affixed to it. If the application does not reach the Controller of Insurance at least 30 days before the date on which the last licence ceases to be in force, Government of India Insurance stamp to the value of Rs 7 should be affixed to the application by way of penalty. In this connection please also refer to the provisos to Rule 16-A of the Insurance Rules, 1939.
6. Payment in CASH OR BY MONEY ORDER, CHEQUE, POSTAL ORDER, POSTAGE OR BANK DRAFT is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required the application should be sent by registered post (acknowledgment due).
Not transferable
Form V-PB
Government of India
Office of The Controller of Insurance
Licence No. . . . . . . . . . . . .
(See Rule 16-A of the Insurance Rules, 1939)
Licence to Act as an Insurance Agent under Part II of the Insurance Act, 1938, for General Insurance Business only
To be filled in by the applicant
Name . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . having paid the prescribed fee and having made the necessary declaration is hereby authorised to act as an Insurance Agent for three years from . . . . . . . . . . . . . . . . . . . . . .
Simla, dated . . . . . . . . . . . . . . . . . 20 .
Controller of Insurance.
Signature of licence holder . . . . . . . . . . . . . . . .
The licence is not valid unless it bears a facsimile of the signature of the Controller of Insurance and the initials of a person authorised by him in this behalf and the signature of the licence holder. The latter should put his signature as soon as the licence is received.
____________________________________________________________________________
Notes
1. If it is desired to renew this licence for a further period, the procedure laid down in Rules 16 and 16-A of the Insurance Rules, 1939, shall be followed, and an application for renewal should reach the Controller of Insurance before the licence expires. In this connection attention is also invited to the provisos to Rule 16-A of the Insurance Rules, 1939.
2. This licence authorises the licence holder to act as an agent for registered insurer and for any class of general insurance business, and therefore no identifying mark or note of any description by which the identity of an insurer might be established should be placed on the licence.
3. No correction in this licence will be valid unless initialled by the Controller of Insurance or a person authorised by him in this behalf.
69[Form V-S
Application from a Co-Operative Society or Panchayat for a Licence to Actas an Insurance Agent
(See Rule 16-A of the Insurance Rules, 1939)
To
The Controller of Insurance,
Simla.
Dear Sir,
It is requested that a licence to act as an Insurance Agent may be granted to our Co-operative Society/Panchayat, particulars given below:
| |
1. Full name of the applicant |
1. Co-operative Society/Panchayat |
| |
(In Block Letters) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . |
| |
2. Full address |
2.. . . . . . . . . . . . . . . . . . . . . . . . . . . |
| |
|
. . . . . . . . . . . . . . . . . . . . . . . . |
2. It is hereby declared that
*Co-operative Society*registered
(i) Our has been under the**.
Panchayatincorporated
*(Please see footnotes also)**
Act . . . . . . . . . . . . . and is competent to act as an insurance agent vide Section . . . . . . . . . . . . . . of the above Act;
(ii) the Society/Panchayat has also been authorised to act as an insurance agent under its by-laws, rules and regulations (vide rules/by-law . . . . . . .);
(iii) the particulars given above are true and that the licence for which our *Co-operative Society/Panchayat apply will be used only by our *Co-operative Society/Panchayat for soliciting or procuring insurance business; and
(iv) the undersigned has been duly authorised to sign this application.
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Government of India Insurance Stamps for Rs 15 |
|
| |
|
|
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Yours faithfully, |
| Name of Place . . . . . . . . . . . . . |
Signature with name and designation |
| Dated the . . . . . . . . . . . . . . . . |
(Seal of the Co-operative Society/Panchayat.) |
*Strike out portions not required.
**Here mention the name of the Central/State Act, under which the institution is registered or incorporated.
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years or with fine which may extend to one thousand rupees, or with both.
2. A licence can be granted to a Co-operative Society/Panchayat registered or incorporated under any Central or State Act.
3. A copy of the by-laws, Rules or Regulations of the applicant certified by its President or Chairman must accompany this application.
4. The application should be filled in, as far as possible, in English language.
5. Any correction or alteration made in any answer to the questions in the application should be initialled by the applicant.
6. Payment in CASH OR BY MONEY ORDER, CHEQUE, POSTAL ORDER, POSTAGE STAMP OR BANK DRAFT is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required the application should be sent by registered post (acknowledgment due).
Form V-SA
Application from a Co-Operative Society or Panchayat for Renewal of a Licence to Act as an Insurance Agent
(See Rule 16-A of the Insurance Rules, 1939)
From
Name of applicant . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . .
(In Block Letters)
Full address . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . .
(In Block Letters)
To
The Controller of Insurance,
Simla
Licence No. . . . . . . . . . . . . . . . . .
Date of expiry . . . . . . . . . . . . . . .
Dear Sir,
It is requested that the above licence may be renewed for a further period of three years.
2. *It is hereby declared that
*(Please see footnote also.)
(i) our *Co-operative Society/Panchayat has been *registered/incorporated under the**. . . . . . . . . . . Act, . . . . . . . . . . . . . and is competent to act as an insurance agent vide Section. . . . . . . . . . . of the above Act;
(ii) the Society/Panchayat has also been authorised to act as an insurance agent under its By-laws, Rules and Regulations (vide Rule/By-law. . .);
(iii) the particulars given above are true and that the licence for which our *Co-operative Society/Panchayat apply will be used only by our Co-operative Society/Panchayat for soliciting or procuring insurance business; and
(iv) the undersigned has been duly authorised to sign this application.
| |
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|
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Government of India Insurance Stamps for Rs 15 |
|
| |
|
|
| |
Yours faithfully, |
| Name of Place . . . . . . . . . . . . . |
Signature with name and designation |
| Dated the . . . . . . . ., 20. |
(Seal of the Co-operative Society/Panchayat.) |
*Strike out portions not required.
**Here mention the name of the Central/State Act under which the institution is registered or incorporated.
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. The name and the licence number given in the application should be identical with those shown in the last licence held. If there is any subsequent change in the name, the reasons for the same should be stated furnishing documentary evidence for the same.
3. Any correction or alteration made in the application should be initialled by the applicant.
4. The application should be filled in, as far as possible, in the English language.
5. The application should reach the Controller of Insurance before the expiry of the last licence held by the applicant but not more than three months before such expiry and Government of India Insurance stamp for Rs 15 should be affixed to it. If the application does not reach the Controller of Insurance at least 30 days before the date on which the last licence ceases to be in force, Government of India Insurance Stamp to the value of Rs 7 should be affixed to the application by way of penalty. In this connection also refer to the provisos to Rule 16-A of the Insurance Rules, 1939.
6. Payment in CASH OR BY MONEY ORDER, CHEQUE, POSTAL ORDER, POSTAGE STAMP OR BANK DRAFT is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required the application should be sent by registered post (acknowledgment due).
Form V-SB
Government of India
Office of The Controller of Insurance
Licence No. . . . . . . . . . . .
(See Rule 16-A of the Insurance Rules, 1939)
Licence to Act as an Insurance Agent under Part II of the Insurance Act, 1938
NAME . . . . . . . . . . . . . . . . .
ADDRESS . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
(To be filled in by the applicant)
(See notes)
having paid the prescribed fee and having made the necessary declaration is hereby authorised to act as an Insurance Agent for three years fromSimla, dated the, 20.
Controller of Insurance
Signature and seal of Licence holder . . . . . . . .
This licence is not valid unless it bears a facsimile of the signature of the Controller of Insurance and the initials of a person authorised by him in this behalf and the signature of the licence holder. The latter should put his signature and seal as soon as the licence is received.
Notes
1. If it is desired to renew this licence for a further period, the procedure laid down in Rules 16 and 16-A of the Insurance Rules, 1939, shall be followed and an application for renewal should reach the Controller of Insurance before the licence expires. In this connection, attention is also invited to the provisos to Rule 16-A of the Insurance Rules, 1939.
2. No correction in this licence will be valid unless initialled by the Controller of Insurance or a person authorised by him in this behalf.]
70[Form V-SS
Application from a Society Registered underthe Societies Registration Act, 1860, for aLicence to Act as an Insurance Agent
(See Rule 16-A of the Insurance Rules, 1939)
To
The Controller of Insurance,
Simla.
Dear Sir,
It is requested that a licence to act as an INSURANCE AGENT may be granted to our Society, particulars given below
| 1. Full name of the applicant |
1. Society |
| (In Block Letters) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 2. Full address |
2.. . . . . . . . . . . . . . . . . . . . . . . . . . . |
| |
. . . . . . . . . . . . . . . . . . . . . . . . |
11. It is hereby declared that
(i) Our Society has been *registered/incorporated under the Societies Registration Act, 1860 (21 of 1860)
(ii) the Society has been authorised to act as an insurance agent under its Bye-laws, Rules and Regulations (vide Rule/Bye-law. . . . . . . . . . . .)
(iii) the particulars given above are true and that the licence for which our Society apply will be used only by our Society for soliciting or procuring insurance business; and
(iv) the undersigned has been duly authorised to sign this application.
Yours faithfully,
| |
|
|
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Government of India Insurance Stamps for Rs 15 |
|
| |
|
|
| Name of Place . . . . . . . . . . . . |
Signature with name and designation |
| Date . . . . . . . . . . . . . . . . . |
|
| |
(Seal of the Society) |
*Strike out portions not required.
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of this Act wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years or with fine which may extend to one thousand rupees, or with both.
2. A licence can be granted to a Society registered or incorporated under the Societies Registration Act, 1860.
3. A copy of the Bye-laws, Rules or Regulations of the applicant certified by its President or Chairman must accompany this application.
4. The application should be filled in, as far as possible, in English language.
5. Any correction or alteration made in any answer to the questions in the application should be initialled by the applicant.
6. Payment in CASH OR BY MONEY ORDER, CHEQUE, POSTAGE STAMP OR BANK DRAFT is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required, the application should be sent by registered post (acknowledgment due).
Form V-SSA
Application from a Society Registered under theSocieties Registration Act, 1860, for renewal ofa Licence to Act as an Insurance Agent
(See Rule 16-A of the Insurance Rules, 1939)
From
Name of applicant . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . .
(In Block Letters)
Full address . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . .
(In Block Letters)
To
The Controller of Insurance,
Simla
Licence No. . . . . . . . . . . . . . . . .
Date of expiry. . . . . . . . . . . . . . .
Dear Sir,
It is requested that the above licence may be renewed for a further period of three years.
2. *It is hereby declared that
*(Please see footnote also).
*registered
(i) Our Society has been under the Societies Registration Act, 1860
incorporated
(ii) the Society has also been authorised to act as an insurance agent under its Bye-laws, Rule and Regulations (vide Rule/Bye-law . . . . . . . . . . . . . . . . .);
(iii) the particulars given above are true and that the licence for which our *Society apply will be used only by our Society for soliciting or procuring insurance business; and
(iv) the undersigned has been duly authorised to sign this application.
Yours faithfully,
Signature with name and designation
(Seal of the Society)
| |
|
|
| |
Government of India Insurance Stamps for Rs 15 |
|
| |
|
|
Name of Place . . . . . . . . . . . . . . . . .
Dated the . . . . . . . . . . . . . . . . . 20.
*Strike out portions not required.
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement, false in any material particular, knowing it to be false shall be punishable with imprisonment for a term which may extend to three years or with fine which may extend to one thousand rupees, or with both.
2. The name and the licence number given in the application should be identical with those shown in the last licence. If there is any subsequent change in the name, the reasons for the same should be stated furnishing documentary evidence for the same.
3. Any correction or alteration made in the application should be initialled by the applicant.
4. The application should be filled in, as far as possible, in the English language.
5. The application should reach the Controller of Insurance before the date of expiry of the last licence held by the applicant but not more than three months before such expiry and Government of India Insurance stamp for Rs 15 should be affixed to it. If the application does not reach the Controller of Insurance at least 30 days before the date on which the last licence ceases to be in force, Government of India Insurance stamp to the value of Rs 7 should be affixed to the application by way of penalty. In this connection also refer to the provisos to Rule 16-A of the Insurance Rules, 1939.
6. Payment in CASH OR BY MONEY ORDER, CHEQUE, POSTAL ORDER, POSTAGE STAMP OR BANK DRAFT is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required the application should be sent by registered post (acknowledgment due).
Not transferable
Form V-SSB
GOVERNMENT OF INDIAOFFICE OF THE CONTROLLER OF INSURANCE
LICENCE NO. . . . . . . . . . . . .
(See Rule 16-A of the Insurance Rules, 1939)
Licence to Act as an Insurance Agent under Part II of the Insurance Act, 1938
| To be filled in |
.png) |
NAME . . . . . . . . . . . . . . . . |
| by the |
|
| applicant |
ADDRESS . . . . . . . . . . . . . |
having paid the prescribed fee and having made the necessary declaration is hereby authorised to act as an Insurance Agent for three years from . . . . . . . . . . . . . . . Simla, dated the . . . . . . . . . . ., 20.
Controller of Insurance.
Signature and seal of licence holder . . . . . . . . . . . . .
This licence is not valid unless it bears a facsimile of the signature of the Controller of Insurance and the initials of a person authorised by him in this behalf and the signature of the licence holder. The latter should put his signature and seal as the licence is received.
Notes
1. If it is desired to renew this licence for a further period, the procedure laid down in Rules 16 and 16-A of the Insurance Rules, 1939, shall be followed, and an application for renewal should reach the Controller of Insurance before the licence expires. In this connection, attention is also invited to the provisos to Rule 16-A of the Insurance Rules, 1939.
2. No correction in this licence will be valid unless initialled by the Controller of Insurance or a person authorised by him in this behalf.
Form V-C
Application for a Certificate to Act as a Principal/Chief/Special Agent
[See Rule 16-D(a)]
To
The Controller of Insurance,
Simla.
Dear Sir,
It is requested that a certificate to act as a Principal/Chief/Special Agent may be granted to me/our Firm/our Company. I/We am/are/will be working for . . . . . . . . . . . and the functions that will be entrusted to me/us are . . . . . . . . . . . . . .
*2. It is hereby declared that
(i) I/any partner of our Firm/any director of our Company have/has not been found to be of unsound mind by a court of competent jurisdiction;
(ii) I/any partner of our Firm/any director of our Company have/has 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;
(iii) I/any partner of our Firm/any director of our Company have/has not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or misrepresentation against an insurer or an 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
(iv) I/any partner of our Firm/any director of our Company am/is not a minor.
3. It is also declared that particulars given below are true and that the certificate for which I/our Firm/our Company apply will be used only by myself/our Firm/our Company for causing insurance business to be solicited or procured.
| (1) |
Full name of the applicant (in Block Letters) individual Mr/Mrs/Miss |
(1) |
| |
|
Company Firm |
|
| (2) |
Full address |
(2) |
| (3) |
(i) |
(In the case of a firm) the names of all the partners therein |
(3) |
| |
(ii) |
(In the case of a company) the names of the directors |
|
| (4) |
In the case of an individual |
(4) |
| |
(a) |
Date of birth in Christian Era. |
(a) |
| |
(b) |
Age on the date of application |
(b) |
| (5) |
Did the applicant ever apply for a certificate to act as a Principal/Chief/Special Agent before? If so, state: |
(5) |
| |
(a) |
Whether the certificate was granted, and in that case the no. and date of expiry of the last certificate; |
(a) |
| |
(b) |
Whether the certificate was refused. In that case the no. and date of the letter conveying refusal of the certificate; |
(b) |
| |
(c) |
Whether the certificate was granted but subsequently cancelled. In that case the no. and date of the letter conveying cancellation of certificate. |
(c) |
| (6) |
If the applicant holds a licence to act as an Insurance Agent and/or a certificate or certificates to act as a principal Agent and/or a Chief Agent and/or a Special Agent, state no. and date of expiry of licence and/or certificate or certificates held. If no licence or certificate is held, say Nil. If a licence or certificate has been applied for, state the date of the application. |
(6) |
N.B. Replies to (a), (b) and (c) to be given only if the reply to the main query is in the affirmative.
*Strike out portion not required.
Government of India Insurance Stamps.
| Principal Agent |
Rs 25/- |
| Chief Agent |
Rs 25/- |
| Special Agent |
Rs 10/- |
| (Please see notes below) |
|
Name of place
Date
Yours faithfully
(Signature of applicant)
Notes
1. The attention of the applicant is drawn to Section 104 of the Act, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. The fee for obtaining a certificate to act as Principal Agent and a Chief Agent is Rs 25 and the fee for obtaining a certificate to act as a Special Agent is Rs 10.
3. The application should be filled in the English language.
4. Any correction or alteration made in any answer to the question in the application should be initialled by the applicant.
5. Payment in cash or by money order, cheque, postal order, postage stamp or bank draft is not accepted and will be returned at the applicant's cost.
6. No acknowledgment of this application will be sent. If one is required, the application should be sent by registered post (acknowledgment due).
7. In the case of a special agent it is not necessary to state the functions, entrusted to him.
Form V-D
Application for Renewal of Certificate to Act as a Principal/Chief/Special Agent
[See Rule 16-D(a)]
From Mr/Mrs/Miss/Messrs
(Name of Principal/Chief/Special Agent)
(In Block Letters)
Full address
(In Block Letters)
To
The Controller of Insurance,
Simla
Dear Sir,
Certificate No.
Date of Expiry.
It is requested that the above certificate may be renewed for a further period of one year.
*2. It is hereby declared that since the date of my/our Firm's/our Company's last application for a certificate
(i) I/any partner of our Firm/any director of our Company have/has not been found to be of unsound mind by a court of competent jurisdiction;
(ii) I/any partner of our Firm/any director of our Company have/has 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;
(iii) I/any partner of our Firm/any director of our Company have/has not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or misrepresentation against an insurer or an insured in the course of any judicial proceedings 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
(iv) my/our firm's/our company's certificate has not been cancelled at any time by the Controller of Insurance.
3. A certificate from the insurer for whom I am/we are working, viz., . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name of Insurer)
to the effect that in the preceding calendar year the provisions of clauses 2 and 3 of Part A/clauses 2 and 4 of Part B/clauses 2 and 3 of Part C of the Sixth Schedule to the Insurance Act, 1938, have been complied with by me/us is attached. The functions entrusted to me/us by the said insurer since the certificate was last renewed or issued were. . . . . . . . . . . . . . . . . . . . . .
| *4. |
I/We hold/have applied for |
.png) |
a licence to act as an insurance Agent No. . . . . . . . . . expiring on . . . . . . . . . . . . . . a certificate to act as a Principal Agent No. P.A. . . . . . . . . . . expiring on. . . . . . . . . . . a certificate to act as a Chief Agent No. C.A. . . . . . . . . . . . . . expiring on. . . . . . . . . . a certificate to act as a Special Agent No. S.A. . . . . . . . . . . . . expiring on. . . . . . . . . . |
| *5. |
I/We neither hold nor have applied for |
.png) |
a licence to act as an Insurance Agent a certificate to act as a Principal Agent a certificate to act as a Chief Agent a certificate to act as a Special Agent |
*Strike out portion not required.
6. It is also declared that the facts stated herein are true and that the certificate for which I/we hereby apply will be used only by myself/ourselves for causing insurance business to be solicited or procured.
| |
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|
| |
Government of India Insurance Stamps(s) vide note 5 |
|
| |
|
|
Yours faithfully
(Signature of the applicant)
Dated the, 20.
Notes
1. The attention of the applicant is drawn to Section 104 of the Act, which provides that whoever in any document required for the purposes of any of the provisions of the Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. The name and the certificate number given in the application should be identical with those shown in the last certificate held. If there is any subsequent change in the name, the reasons for the same should be stated furnishing documentary evidence for the same.
3. Any correction or alteration made in any answer to the questions in the application should be initialled by the applicant.
4. The application should be filled in the English language.
5. The application should reach the Controller of Insurance not earlier than three months before, but not later than 12 months after the last certificate held by the applicant expires and a Government of India Insurance Stamp for Rs 25 in the case of a principal agent or a chief agent and for Rs 10 in the case of a special agent should be affixed to it.
An additional stamp for Rs 5 in the case of a principal agent or a chief agent and Rs 3 in the case of a special agent must be affixed, if the application reaches the Controller of Insurance on or after the date on which the last certificate held by the applicant ceases to be in force. Any application reaching the Controller of Insurance after a period of twelve months from that date, will be treated as an application for a fresh certificate.
6. Payment in cash or by money order, cheque, postal order, postage stamp or bank draft is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required, the application should be sent by registered post (acknowledgment due).
8. In the case of special agent it is not necessary to state the functions entrusted to him.
Not transferable
Form V-E
Government of India
Office of The Controller of Insurance
Govt. Crest
CERTIFICATE NO.
[See Rule 16-D(c)]
Certificate to Act as a Principal/Chief/Special Agent under Section 42-A of the Insurance Act, 1938
Name
Address
having paid the prescribed fee and having made the necessary declaration is hereby authorised to act as a Principal/Chief/Special Agent for one year from Simla, dated the,20.
Signature of Certificate holder.
Controller of Insurance.
The Certificate is not valid unless it bears a facsimile of the signature of the Controller of Insurance or the initials of a person authorised by him in this behalf and the signature of the certificate holder. The latter should put his signature as soon as the certificate is received.
Notes
1. If it is desired to renew this certificate for a further period, the procedure laid down in Rule 16-D of the Insurance Rules, 1939, shall be followed, and an application for renewal should reach the Controller of Insurance not earlier than three months before, but not later than 12 months after, the certificate expires.
2. No correction in this certificate will be valid unless initialled by the Controller of Insurance or a person authorised by him in this behalf.
Form V-F
(See Rule 17)
From
(Name)
(Occupation)
(Address)
To
The Directors
Insurance Co. Ltd.
In connection with my request for the transfer of Shares Nos. . . . . . . . . . . . . . . . . . of your company to my name, I hereby solemnly declare that out of the above shares, I propose:
| (1) |
to hold Shares Nos. |
for my own benefit |
| (2) |
to hold |
|
|
| |
(i) (a) Shares Nos. (b) Jointly with (Name and Address) (Name) (Occupation) (Address) |
as a nominee. for the benefit of |
| |
(ii) (a) Shares Nos. (b) Jointly with (Name and Address) (Name) (Occupation) (Address) |
as a nominee for the benefit of |
| |
(iii) (a) Shares Nos. (b) Jointly with (Name and Address) (Name) (Occupation) (Address) |
as a nominee. for the benefit of |
| |
(iv) (a) Shares Nos. (b) Jointly with (Name and Address) (Name) (Occupation) (Address) |
as a nominee. for the benefit of |
| made at |
a.m. on p.m. |
day the |
at
Signature.
In the presence of (Witness) Signature
Name and Address
Notes
1. If the beneficial interest of any person is limited in extent in any way, the extent or beneficial interest should be clearly stated.
2. Strike off these words in cases where the nominee does not hold the shares jointly with any other person or persons.
3. Each beneficial ownership is to be stated separately.
Form V-G
(See Rule 17-A)
From
(Name)
(Occupation)
(Address)
To
The Directors
Insurance Co. Ltd.
In connection with Shares Nos. . . . . . . . . . . . . . . . . . of your company standing in your share register in the name of (name) . . . . . . . . . . . . . . . . . (occupation) . . . . . . . . . . . . . . . . . (address) . . . . . . . . . . . . . . . . ., I hereby solemnly declare that out of the above shares.
(i) I am the sole beneficial owner of Shares Nos.and I acquired the beneficial interest before the commencement of the Insurance (Amendment) Act, 1950,
| |
on the |
day of |
, 20 . |
| (ii) |
in respect of Shares Nos. |
|
, I and (name) |
| |
(occupation) |
|
(address) |
| |
and (name) |
|
(occupation) |
| (address)are jointly beneficial owners, my interest in these shares being limited toand was acquired before the commencement of the Insurance (Amendment) Act, 1950. |
on theday of, 20.
Made onday the, 20. at
In the presence of
(witness) Signature
Name and Address
Signature.
I, . . . . . . . . . . . . . . . . . of . . . . . . . . . . . . . . . . . in whose name the Shares Nos. . . . . . . . . . . . . . . . . . of your company stand in your share register, hereby recognise in full the interest claimed in respect of the said shares and in token thereof have countersigned the above declaration.
Signed on theday of the, 20.
Signature
In the presence of
(Witness) Signature
Name and Address
71[Form V-GG
(See Rule 17-AA)
From
(Name)
(Occupation)
(Address)
To
The Directors
Insurance Co. Ltd.
In connection with Shares Nos. . . . . . . . . . . . . . . . . . of your company standing in your share register in the name of (name) . . . . . . . . . . . . . . . . . (occupation) . . . . . . . . . . . . . . . . . (address) . . . . . . . . . . . . . . . . . . . . . .
I hereby solemnly declare that out of the above shares,
(i) I am the sole beneficial owner of Shares Nos. and I acquired the beneficial interest before the commencement of the Insurance (Amendment) Act, 1968 (62 of 1968).
| |
on the |
day of |
, 20 . |
| (ii) |
in respect of Shares Nos. |
|
, I and (name) |
| |
(occupation) |
|
(address) |
| |
and (name) |
|
(occupation) |
| (address)are jointly beneficial owners, my interest in these shares being limited to and was acquired before the commencement of the Insurance (Amendment) Act, 1950. |
on theday of, 20.
made onday the, 20. at
in the presence of
(Witness) Signature
Name and Address
Signature.
I, . . . . . . . . . . . . . . . . . of . . . . . . . . . . . . . . . . . in whose name the Shares Nos. . . . . . . . . . . . . . . . . . of your company stand in your share register, hereby recognise in full the interest claimed in respect of the said shares and in token thereof have countersigned the above declaration.
Signed on theday of the, 20.
In the presence of
(Witness) Signature
Name and AddressSignature.]
Form V-H
(See Rule 17-C)
Statement of the bases of Premiums
Name of the insurer
1. Basis:
Mortality
Rate of interest
Expenses
Bonus loading
The above basis is the basis underlying the premium in Tables Nos.of the prospectus, datedissued by
Company Limited
2. Basis:
Mortality
Rate of interest
Expenses
Bonus loading
The above basis is the basis underlying the premiums in Tables Nos.of the prospectus, datedissued by
Company Limited.
I hereby certify that the bases underlying the premium rates offered by Company Limited are as set out above.
Station
DateActuary
Notes
1. The premiums may be grouped according to bases and into as many groups as may be necessary and set out one group after another till all the premium tables and premiums offered outside the tables are conversed.
2. If different bases have been used for different ages and terms in the same table of rates, these should be stated separately.
Form VI-A
[See Rule 19-A(i)]
Register of members (excluding membership merely by virtue of holding policies issued by the Society) proprietors and shareholders
| Serial No. |
Date of becoming member, proprietor, or shareholder, as defined in heading |
Full name |
Address |
Occupation |
Date on which ceased to be a member, etc. |
Remarks |
| |
|
|
|
|
|
|
Form VI-B
[See Rule 19-A(ii)]
Register of Directors, Manager, Secretary and Officers
| Serial No. |
Full name |
Address |
Occupation other than in the service of the society |
Date when he commenced to hold the office in question |
Date of ceasing to hold the office in question |
Remarks |
| |
|
|
|
|
|
|
Notes
1. A separate page must be used for each title of office, viz., Secretary.
2. Remarks column should show the mode of vacating office, whether by death, resignation, retirement, etc.
Form VI-C
[See Rule 19-A(iii)]
Proposal Register
| Serial No. |
Date and number of proposal |
Name and address of proposer |
How disposed of* |
Date of acceptance, if accepted* |
Number and date of policy* |
Date of dispatch of policy* |
Remarks |
| |
|
|
|
|
|
|
|
Notes
*In case proposal is rejected or does not result in a policy, against Columns 4 to 7 the amount of advance or deposit received, if any and the date of its adjustment with reasons or the date of its refund should be stated.
Form VI-D
[See Rule 19-A(iv)]
Register of policies issued
| Serial No. |
Number and date of proposal |
Policy number and date of commencement of insurance* |
Date and mode of exit with cross-reference to the exit register concerned |
Name, occupation and address of life insured |
Name and address of person paying the premiums of other than life insured and his relationship to life insured |
Name and address of each nominee and his relationship to the policy-holder and the date of registration of each nomination and of receipt of notice of cancellation or change thereof, if any |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
| |
|
|
|
|
|
|
| |
|
|
|
|
|
|
| Term of policy and full particulars of the table under which the policy is issued . |
Sum insured |
Premium Amount of each instalment and due date of final instalment |
**The percentages of the first year and renewal premiums prescribed in the society's rules for expenses |
**Amount that can be expended on the basis of Columns 9 and 10 |
Due dates of all instalments in each calendar year |
If assigned, name and address of each assignee and dates on which the respective notices were received |
| 8 |
9 |
10 |
11 |
12 |
13 |
14 |
| |
|
|
|
|
|
|
Notes
*Cross reference should be given to other policies, if any, if the contingencies on the happening of which the sums insured are payable under those policies relate to the same person as under this policy.
The entries regarding exit should be shown in pencil, when the exit is capable of revival and erased on subsequent revival. When revival is no longer possible the pencil entries should be replaced by ink.
In case of contingencies other than death, in Columns 4 and 5, substitute for the words the life insured the words the person to whom the contingencies on the happening of which sums are payable relate .
If the sum insured excluding bonus varies during the term of the policy, both the maximum and minimum of the sum insured should be stated. Where a policy has been made paid-up, necessary correction shall be made to the sum assured by showing the paid-up amount and the date of making it paid-up shall also be indicated.
**If a uniform percentage (irrespective of the tables and premium terms of policies) is fixed for expenses of management or if a separate register of premium receipts for each group of premiums having the same percentage allowance for expenses is maintained this column need not be filled in.
Form VI-E
[See Rule 19-A(v)]
Premium Register in respect of all premiums falling due during the month of . . . . . . . . . . . . . . . . ., 20.
| Policy No |
Name of the person to whom the policy was issued |
Due date of premium |
Date of payment of premium |
Amount of premium |
Amount out of the premium stated in Column 5 that can be spent as expenses of management as per rules of the society (to the nearest anna) |
Particulars of any other payment as fees, fines, etc., realised on the policy during the month |
| |
|
|
|
|
|
|
Notes
1. The register should be closed at the end of each month and the closing should be completed within a month.
2. Separate register should be maintained in respect of each of the contingencies specified in or prescribed under Section 65(2) of the Insurance Act, 1938.
3. Particulars relating to a new policy shall be entered in the month in which the first premium is received. Particulars to a revived policy shall be entered in the month in which the policy is revived.
4. If a uniform percentage is fixed for expenses of management, irrespective of the tables and premium-terms of policies or if a separate register of premium receipts for each group of premiums having the same percentage allowance for expenses is maintained, Column 6 need not be filled in.
5. A society may, if it considers necessary and desirable, maintain a separate register of the particulars specified in Column (7), provided that the separate register gives also the information in Columns (1) and (2) with full cross references with this register.
Form VI-F
[See Rule 19-A(vi)]
Lapse Register
| Date of entry in this register |
Policy Number |
Name of the insured |
Date of commencement of insurance |
Due date of first unpaid premium |
Amount of any loan granted on the security of the policy and date when the loan is written off |
Date of revival (if any) |
| |
|
|
|
|
|
|
Notes
The register should be closed at the end of each month and the closing shall be completed within a month.
Form VI-G
[See Rule 19-A(vii)]
Register of claims not including annuities
| Sl. No. |
Policy No. |
Name of life insured |
Date of intimation of the happening of the contingency |
Name, Address and title of claimant |
Date of receipt of claim papers |
Date of payment |
Total sum insured with bonus additions up-to-date |
Net sum paid in cash |
Cause of difference if any between (8) and (9) |
Date of and ground for rejection, if any |
| |
|
|
|
|
|
|
|
|
|
|
Notes
1. Where there is a series of policies on the same life, each policy must be entered separately.
2. A separate register should be maintained for each class of contingency specified in or prescribed under Section 65(2) of the Insurance Act, 1938, against which policies have been issued.
Form VI-H
[See Rule 19-A(viii)]
Register of claims for annuities or other periodical payments
Serial No. . . . . . . . . . . . . . . .Policy No. . . . . . . . . . . . . . . .
Name of life insured . . . . . . . . . . . . . . . . . . . . .
Date of intimation of the happeningDate of receipt of Claim
of the contingency. . . . . . . . . . . . .papers . . . . . . . . . . . . . . . . . . . .
Name
Addressof claimant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Title. . . . . . . . . . . . . . . . . . . . . . .
Date of first payment . . . . . . . . . . . Date and ground of rejection. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date and Cause of cessation of payments . . . . . . . . . . . . . . . . . . . . . . . . . .
| Due dates |
Amounts due |
Amounts paid in cash and date |
Case of difference, if any |
| |
|
|
|
Notes
A separate register should be maintained for each class of contingency specified in or prescribed under Section 65(2) of the Insurance Act, 1938, in respect of which a periodical sum is insured to be paid.
Form VI-I
[See Rule 19-A(ix)]
Register of Agents
| Serial No. |
Name, address and all other occupations |
Date of appointment |
Terms of remuneration |
Date when ceased to be agent |
Remarks |
| 1 |
2 |
3 |
4 |
5 |
6 |
Form VII
(See Rule 20)
Revenue Account of the(here insert name of providentsociety) for the year ending, 20.
Rsp
Dividends to shareholders payable on for the year ending . .. .
(This is to be stated here by societies not supplying a Profit and
Loss Account). .. .. .. .. .
Claims under policies (including provision for claims due or intimated)
Rsp
To be specified separately according to the classes of
contingency set forth in Section 65
Other classes (to be separately specified) . .. .. .
___________
Annuities. .. .. .. .. .
Surrenders including surrenders of bonus. .. .. .
Bonuses in cash. .. .. .. .. .
Bonuses in reduction of premiums expenses of management
1. Commission to agents. .. .. .. .
2. Commission and allowances other than those payments
contained in Item 1. .. .. .. .. .
3. Salaries, etc. (other than those contained in Items 1 and 2). .
4. Travelling expenses. .. .. .. .. .
5. Directors' fees. .. .. .. .. .
6. Auditors' fees. .. .. .. .. .
7. Actuarial fees. .. .. .. .. .
8. Medical fees. .. .. .. .. .
9. Law charges. .. .. .. .. .
10. Advertisements. .. .. .. .. .
11. Printing and stationery. .. .. .. .
12. Rents for offices belonging to and occupied by the Society. .
13. Rents of other offices occupied by the society. .. .
14. Other expenses of management (to be specified). .. .
Bad debts. .. .. .. .. .
Other payments (accounts to be specified). .. .. .
Shareholders' capital paid up at the end of the year as per
balance-sheet. .. .. .. .. .
Profit transferred to Profit and Loss Account (if a Profit
and Loss Account is submitted). .. .. .. .
Balance of funds at the end of the year as per balance-sheet
Rsp
Funds, specified separately according to the classes of
contingency set forth in Section 65. .. .. .. .
Investment Reserve Fund, Dividend Reserve Fund,
Other funds (to be separately described). .. .
Rsp
Balance of Funds at the beginning of the year
Funds specified separately according to the classes of contingency
set forth in Section 65. .. .. .. .
Investment Reserve Fund, Dividend Reserve Fund,. .. .. .
Other Funds (to be separately described)
_________
Shareholders' capital paid up at the beginning of the year. .
Shareholders' capital paid up during the year. .. .
Premiums
1st yearRenewalSingle
prms.prms.prms.
Rs pRs pRs p
To be specified separately according to the
classes of contingency set forth in
Section 65. .. .
Insuring other benefits (to be separately
specified). .. .
Total premiums. .. .Rs p
Consideration for annuities granted. .. .. .
Interest, dividends and rents. .. .. .
Less Income tax. .. .. .. .
Entrance fees. .. .. .. .
Fines. .. .. .. .
Other income (accounts to be specified). .. .
(Loss transferred to Profit and Loss Account if a Profit
and Loss Account is submitted) . .. .. .
Notes relating to the Revenue Account (Form VII)
1. All items in this account shall be net amounts after deduction of the amounts paid and received in respect of reassurance of the society's risks.
2. A society transacting more than one class of business shall show in its accounts the premium income, the claims and the funds separately for business under each class of contingency prescribed or authorised under Section 65. (See Rule 18.)
3. If any sum has been deducted from the expenses and credit has been taken for it in the balance-sheet as an asset the sum so deducted shall be shown in a separate statement, as follows:
Statement regarding preliminary expenses, etc. submitted by thefor the year ending, 20.
Rs
| Balance at beginning of year either of the adverse balance of any profit and loss or revenue account or such bad debts and preliminary and other expenses as may not have been included in the profit and loss or revenue account either as loss or outgo but for which credit is taken in the balance-sheet as assets. .. . |
|
| Addition hereto during the year not shown as loss or outgo in either the profit and loss or revenue account |
|
| Total Rs |
|
| |
Rs |
| Less amount written off during the year as per profit and loss or revenue account Balance at the end of year is still shown as assets in the balance sheet |
|
4. The society may, if it so desires, show in this account the amount of commission on new business separately from commission on renewal premiums.
5. The items on the income side shall relate to income whether actually received or not and items on the expenditure side shall relate to expenditure whether actually paid or not.
6. Any office premises which form part of the assets of any fund of the society shall be treated as an interest earning investment and accordingly in the revenue account a fair rent for the premises shall be included under the heading Interest, Dividends and Rents and a proper charge for the use thereof shall be included in the appropriate place in the expenses of management.
7. The following information shall be supplied in addition, namely, the gross premium income for each class of contingency for which the net premium income is shown separately in the revenue account and a statement in Form VII-A of the particulars specified therein. (See Note 1.)
Form VII-A
Submitted by the. . . . . . . . . . . Society. . . . . . . . . . . . for theyear ending. . . . . . . ., 20 .
| |
|
Policies insuring money to be paid on death only |
Policies insuring money to be paid only on survivance or earlier death |
Annuities |
Marriage policies |
And so on for each contingency specified in or prescribed under Section 65(2) of the Insurance Act, 1938, for which separate account is required to be prepared. |
| |
|
No. |
Sum assured |
Reversionary bonus |
No. |
Sum assured |
Revisionary bonus addition |
No. |
Sum insured |
Np. |
Sum insured |
| |
|
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
| |
|
Rs |
|
Rs |
|
Rs |
Rs |
|
Rs |
|
Rs |
|
| (1) |
Policies at end of previous year. |
|
|
|
|
|
|
| (2) |
New policies issued as per Statement Form IX. |
|
|
|
|
|
|
| (3) |
Old policies revived. |
|
|
|
|
|
|
| (4) |
Old policies changed and increased. |
|
|
|
|
|
|
| (5) |
Bonus additions allotted. |
|
|
|
|
|
|
Total
Discontinued during year
| (6) (a) (b) |
*By death amount payable. amount not payable. |
|
|
|
|
|
|
| (7) |
By maturity or the happening of the contingencies insured against (each contingency being shown separately). |
|
|
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|
|
|
| (8) |
By expiry of term. |
|
|
|
|
|
|
| (9) (i) (ii) |
By surrender of policy and Bonuses |
|
|
|
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| (10) |
By forfeiture or lapse |
|
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| (11) |
By change and decrease. |
|
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| (12) |
By being not taken up. |
|
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| |
Total |
|
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|
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| Total existing at the end of the year. |
|
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|
*Note. For sum assured and bonuses, the amount actually payable as per rules of the society should be shown against item (6)(a), while the difference between the total sum assured and the actual amount payable on policies subject to lien becoming claims by death should be shown against (6)(b). The columns for number of policies should be left blank against item (6)(b).
Form VIII
(See Rule 20)
Balance-sheet of. . . . . . . . . . . . . . . as at. . . . . . . . . . . . . . . . . . day of. . . . . . . . . . . ., 20.
| |
Rs p |
|
Rs p |
| |
|
Loans |
|
| Shareholder's capital (each class to be stated separately) |
|
On mortgages of property On security of municipal and other public rates. |
|
| Authorised |
|
On stocks and shares On society's policies within their surrender value |
|
| Shares of Rs each Rs |
|
On personal security To other provident societies and insurers. |
|
| Subscribed |
|
Investments (f) |
|
| |
Rs P. |
|
Rs P. |
| Shares of Rs each Rs |
|
Deposit with the Reserve Bank of India (Securities to be specified). |
|
| |
|
Indian Government Securities. |
|
| |
|
State Government Securities. |
|
| |
|
British, British Colonial and British Dominion Government Securities. |
|
| |
|
Foreign Government Securities. |
|
| Called up |
|
Indian Municipal Securities. |
|
| |
|
British and Colonial Securities. |
|
| |
|
Foreign Securities. |
|
| Shares of Rs each Rs |
|
Bonds, Debentures, Stocks and other Securities whereon interest is guaranteed by the Indian Government or a State Government. |
|
| Less unpaid calls Rs |
| Balances of Funds |
|
Bonds, Debentures, Stocks and other Securities whereon interest is guaranteed by the British or any Colonial Government. |
|
| To be specified separately as shown in the Revenue Account (Form VII). |
|
Bonds, Debentures, Stocks and other Securities whereon interest is guaranteed by any foreign Government. |
|
| Balance of Profit and Loss Account. |
|
|
|
| Debenture stock per cent |
|
Debentures of any railway in India. |
|
| Loans and advances (a) |
|
Debentures of any railway out of India. |
|
| Bills payable (a) |
|
Preference or guaranteed shares of any railway in India. |
|
| Estimated liability in respect of outstanding claims (b). |
|
Preference or guaranteed shares of any railway out of India. |
|
| To be stated separately in respect of each fund shown in the Revenue Account (Form VII). |
|
Railway Ordinary Stocks (i) in India, (ii) out of India. |
|
| |
|
Other Debentures and Debenture. |
|
| Annuities due and unpaid (b). |
|
Stocks of Companies incorporated (i) in India, (ii) out of India. |
|
| Outstanding dividends |
|
Other guaranteed and preference Stocks and shares of Companies incorporated (i) in India, (ii) out of India. |
|
| Sundry creditors (including outstanding and accruing expenses and taxes) (a). |
|
Other ordinary Stocks and shares of Companies incorporated (i) in India, (ii) out of India. |
|
| Other sums owing by the society (a). |
|
Holdings in subsidiary Companies. |
|
| Contingent liabilities (to be specified) (c). |
|
House property (i) in India, (ii) out of India. |
|
| |
|
Other Investments (to be specified). |
|
| |
|
Agents' balances. |
|
| |
|
Outstanding premiums (b) (d). |
|
| |
|
Interest, dividends and rents outstanding (b). |
|
| |
|
Interest, dividends and rents accruing but not due (b). |
|
| |
|
Sundry debtors. |
|
| |
|
Bills receivable. |
|
| |
|
Cash |
|
| |
|
At bankers on Deposit Account. At bankers on Current Account and in hand. Other Accounts to be specified _________ (e). |
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Footnote to Balance-Sheet Form VIII
(a) If the society has deposited security as cover in respect of any of these items the amount and nature of the securities so deposited shall be clearly indicated on the face of the balance sheet.
(b) These items are or have been included in the corresponding items in the revenue account or profit and loss account. Outstanding and accruing interest, dividend and rents shall be shown after deduction of income tax or the income tax shall be provided for amongst the liabilities on the other side of the balance-sheet.
(c) Such items as amount of liability in respect of bills discounted, uncalled capital in respect of other investments, etc., shall be shown in their several categories under the heading contingent liabilities or the appropriate items on the assets side shall be set out in such detail as will clearly indicate the amount of uncalled capital.
(d) Either this item shall be shown net or the commission shall be provided for amongst the liabilities on the other side of the balance-sheet.
(e) Under this heading shall be included such items as the following which shall be shown under separate heading suitably described:
Office furniture, goodwill, preliminary, formation and organisation expenses, development expenditure account, discount on debentures issued, other expenditure carried forward to be written off in future years, adverse balance of profit and loss account, etc. The amounts included in the balance-sheet shall not be in excess of cost.
(f) Where any part of the assets of a provident society is deposited in any place outside the States as security for the owners of policies issued in that place the balance-sheet shall state that part of the assets has been so deposited and, if any such part forms part of the insurance fund in respect of contingency specified in, or prescribed under sub-section (2) of Section 65 of the Insurance Act, 1938, shall show the amount thereof and the place where it is deposited.
Statements and Certificates relating to the Balance-Sheet
I. There shall be appended to the balance-sheet a statement showing separately for every asset which is included in the balance-sheet, the full title and particulars of the asset and the value at which it is included in the above balance-sheet, and in the case of assets being stock exchange securities, the nominal value and the market-value as at the date of the balance-sheet. In stating the market-value of the stock exchange security no credit shall be taken in the statement for accrued interest.
II. To the balance-sheet shall be appended:
(a) A certificate signed by the same persons as are required to sign the balance-sheet certifying that the values of all the assets have been reviewed as at the date of the balance-sheet and that in their belief the assets set forth therein are shown in the aggregate at amounts not exceeding their realisable or market-value under each of the several headings Loans , Investments , Agents' balances , Outstanding premiums , Interest, dividends and rents outstanding , Interest, dividends and rents accruing but not due , Sundry debtors , Bills receivable and the items entered under other accounts :
Provided that if the persons signing the certificate are unable to certify without reservation that the assets set forth in the balance-sheet are so shown as aforesaid, a full explanation shall be given.
(b) A certificate signed by the auditor (which shall be in addition to any other certificate or report he is required by law to give with respect to the balance-sheet) certifying that he has verified the cash balances, the loans and investments.
Form IX
(See Rule 20)
Statement under clause (a)(i) of sub-section (2) of Section 80 in respect of (here insert name of provident society) for the year ending, 20.
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New Policies effected |
Existing policies discontinued |
| .png) |
.png) |
| By happening of contingency insured against |
Surrenders, forfeitures and lapses |
For other reasons |
| Contingencies on which sum assured or other benefit is payable* (Classified according to the contingencies separately specified in Section 65) |
Number of policies Total full sums insured Total premium income received |
No. |
Sum insured and Bonus |
No. |
Sum insured and Bonus |
No. |
Sum insured and Bonus |
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RsRs |
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Rs |
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Rs |
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Rs |
*Where the provident society issues annuities either immediate or deferred, the statement shall show the number of each class of such annuities, the annual sums payable and the consideration received or the annual premium in the case of deferred annuities.
Form X
(See Rule 20)
Statement under clause (b) of sub-section (2) of Section 80 in respect of . . . (here insert name of provident society) for the year ending. . . . . . . . ., 20.
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No. |
Sum insured |
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Rs |
| Policies effected |
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| By husband or wife |
. . |
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| By Son |
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| By daughter |
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| By father |
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| By mother |
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| By brother |
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| By sister |
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| By grandson |
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| By granddaughter |
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| By nephew |
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| By niece |
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| By any other person |
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| Total |
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Form XI
(See Rule 26)
It is hereby certified that all amounts received directly or indirectly at credit of the revenue account in respect of business transacted in India referred to in clause (b) of sub-section (2) of Section 16 of the Act, whether from the head office of the insurer or from any other source outside India, have been shown in the aforementioned revenue account, except such sums as properly appertain to the capital account, and it is further certified that all expenditure including claims, attributable to business in India, met during the year in question from sources arising outside India, has been shown in the said revenue account except such sums as properly appertain to the capital account.
Form XII
(See Rule 27)
Submitted by the . . . . . . . . . . . (here insert name of insurer) for the year ending . . . . .., 20.
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Dividing insurance policies insuring money to be paid on death or survivance |
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Dividing insurance polices insuring money to be paid on marriage |
And so on for each other class of dividing insurance business for which a separate revenue account is submitted |
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No. |
*Minimum sum insured guaranteed |
No. |
*Minimum sum insured guaranteed |
| 1. |
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Policies at beginning of year |
Rs |
Rs |
Rs |
| 2. |
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New policies issued |
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| 3. |
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Old policies revived |
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| 4. |
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Old policies changed and increased |
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| 5. |
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Bonus additions allotted |
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Total |
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Discontinued during year |
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| 6. |
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By death |
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| 7. |
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By survivance or the happening of the contingencies insured against other than death . . |
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| 8. |
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By expiry of term under temporary insurances |
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| 9. |
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By surrender of policy |
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| 10. |
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By surrender of bonus |
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| 11. |
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By forfeiture or lapse |
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| 12. |
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By change and decrease |
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| 13. |
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By being not taken up |
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Total discontinued |
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Total existing at end of year |
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*If there be no minimum amount guaranteed to be paid on the happening of the contingency insured against, the column may remain blank.
Form XIII
(See Rule 27)
Submitted by the . . . . (here insert name of insurer) for the . . . . year ending . . . . . . ., 20.
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Number of dividing insurance policies effected in the year under review insuring sums payable at death or survivance. |
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Under Table No. 1 |
Under Table No. 2 |
And so on for each other table of dividing insurance business insuring sums payable at death or survivance |
| (1) |
Number of policies insuring money to be paid on the death of a male life |
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Effected during the year by |
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the life insured. . |
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His wife. . |
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,, son. . |
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,, daughter. . |
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,, father. . |
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,, mother. . |
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,, brother. . |
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,, sister. . |
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any person other than the above relations |
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| (2) |
Number of the policies insuring money to be paid on the death of a female life |
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Effected during the year by |
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the life insured. . |
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her husband. . |
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,, son. . |
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,, daughter. . |
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,, father. . |
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,, mother. . |
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,, brother. . |
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,, sister. . |
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any person other than the above relations |
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Total number of policies effected in the year |
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If the different tables be not distinguished from one another by numbers, as assumed in the above form, the headings to the form may be altered accordingly.
Form XIV
(See Rule 27)
Submitted by thesocietyfor theyear ending, 20.
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Number of dividing insurance policies effected in the year under review insuring sums payable at death or survivance |
| Age of life on the death of whom the policy monies become payable |
Under Table No. 1 |
Under Table No. 2 |
Under Table No. 3 |
And so on for each other table of dividing insurance business insuring sums payable at death or survivance |
| Under 5 years . . Over 5 and under 10 . . 10 15 . . 15 20 . . 20 25 . . 25 30 . . 30 35 . . 35 40 . . 40 45 . . 45 50 . . 50 55 . . 55 60 . . 60 65 . . 65 70 . . 70 . . |
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| Total number of policies effected in the year |
(These totals should agree with the totals in Form XIII). |
If the different tables be not distinguished from one another by numbers, as assumed in the above form, the headings to the form may be altered accordingly.
Form XV
(See Rule 31)
Statement showing the emoluments (salary or commission or both) paid by the Insurance Company Limited during the year ending 31st December
(Please see notes below)
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Remuneration |
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.png) |
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| Sl. No. |
Name, Qualification and address |
Relationship, if any, with the General Manager, or any Director of the Company with particulars thereof |
Designation |
Nature of any agreement with Company and date of entering into such agreement |
Nature of work done |
Rate of Commission, if any |
Amount of Commission |
Amount of Salary |
Allowance, etc. |
Total of columns (8), (9) and (10) |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
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Notes:
(1) In the case of an insurer specified in sub-clause (a) (ii) or sub-clause (b) of clause (9) of Section 2, the statement should relate to all the insurance business transacted by him and in the case of any other insurer should relate to the insurance business transacted by him in India.
(2) Where the allowance exceeds 20 per cent of the salary or commission paid the nature and particulars of such allowance should be indicated.
(3) For the purpose of this statement all categories of agents are to be included provided the total remuneration paid exceeded Rs 5000 during the year to which the statement relates.
Form XVI
(See Rule 33)
Summary of balance sheet and revenue account of . . . . . . . . . . company . . . . . . . . . . . . . . . . in respect of total business.
Revenue Account for the year ending
| Particulars |
Rs |
Particulars |
Rs |
| Claim, annuities, surrenders and bonuses less reinsurance. |
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Balance of Fund at the beginning of the year. |
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| Expenses of management including commission. |
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Premiums and consideration for annuities, less reinsurances. |
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| Bad Debts |
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Interest, dividend and rents |
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| Other items |
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less Income-tax. |
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| Balance of Fund at the end of the year. |
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Other income |
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| Total |
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Total |
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Balance-sheet as at____________________________ |
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Rs |
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| Life Insurance Fund |
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Government securities |
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| Other Funds |
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Other Approved securities |
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| Reserves |
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Fictitious items and bad assets |
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| Loans and Advances |
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Other assets |
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| Outstanding claims |
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| Other liabilities |
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| Total |
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Total |
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72Form XVII
(See Rule 40)
Warrant of Authorisation under Section 34-H of Insurance Act, 1938 andRule 40 of the Insurance Rules, 1939.
Shri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name and Designation of the Officer)
Whereas information has been laid before me and on the consideration thereof, I have reason to believe that
a requisition under sub-section (2) of Section 33 of the Insurance Act, 1938 by . . . . . . . . . . . to . . . . . . . . . . . . . .. . (name of the person) was served on . . . . . . . . . . (date) to produce or cause to be produced the books, accounts and other documents specified in the requisition and he has omitted or failed to produce or cause to be produced such books, accounts or other documents as required by such requisition.
a requisition under sub-section (2) of Section 33 of the Insurance Act, 1938 by . . . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . . (name of the person) was served on . . . . . . . . . . . . . . . . (date) to produce or cause to be produced the books, accounts and other documents specified in the requisition and he will not produce or cause to be produced such books, accounts, or other documents as required by such requisition.
a contravention of the provisions of section . . . . . . . . . . . . . . this Act has been committed or is likely to be committed by . . . . . . . . . . . . . . . . . . . . .(Name of insurer.)
Claim No. . . . . . . . . . . . . . . . . under Policy No. . . . . . . . . . . . . . . in the class of . . . . . . . . . . . . . . . . . . . . . . . . insurance business which is due to be settled by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name of insurer.)
has been or is likely to be settled at a figure higher than a reasonable amount,
Claim No. . . . . . . . . . . . . . . . . . under Policy No. . . . . . . . . . . . . . . . . . . . . in the class of . . . . . . . . . . . . . . . . . insurance business which is due to be settled by . . . . . . . . . . . . . . . . . . (Name of insurer) has been or is likely to be rejected or settled at a figure lower than a reasonable amount,
An illegal rebate or commission has been paid or is likely to be paid by . . . . . . . . . . . . . . . . . in respect of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name of insurer.)
the books, accounts, receipts, vouchers, survey reports or other documents, specified in the attached list belonging to . . . . . . . . . . . . . . . . . (Name of the insurer) are likely to be tampered with, falsified or manufactured.
And whereas I have reason to suspect that such books, accounts or other documents as are necessary for the purposes of investigation of matters aforesaid, have been kept and are to be found at . . . . . . . . . . . . . (Specify particulars of the building or place).
This is to authorise and require you . . . . . . . . . . . . . . . . . (name of authorized officer)
(a) to enter and search the said premises;
(b) to place identification marks on such books, accounts and documents as may be found in the course of the search and as you may consider relevant to or useful for the purposes of or the investigation of matters aforesaid and to make a list thereof together with particulars of the identification marks;
(c) to examine such books, accounts and documents and make, or cause to be made, copies or extracts from such books of account and documents;
(d) to seize any such books, accounts or documents, found as a result of such search and take possession thereof;
(e) to convey such books, accounts and documents to
(Office).
(f) to exercise all the powers and perform all other functions under Section 34-H of the Insurance Act, 1938 and the rules relating thereto.
You may requisition the services of any Police Officer or any officer of the Central Government, or of both, to assist you for all or any of the purposes specified in sub-section (1) of Section 34-H of the Insurance Act, 1938.
Controller of Insurance.
Form XVIII-AF
Application from a Firm or Company for a Licence to Act as a Surveyor/Loss Assessor
(See Rule 56)
To
The Controller of Insurance,
Simla-4
Dear Sir,
It is requested that a licence to act as a Surveyor/Loss Assessor may be granted to our Firm/Company.
2. The receipt No. . . . . . dated . . . . . . from . . . . . showing payment of fees of Rs 250 is enclosed.
3. It is hereby declared that
(i) any partner of our Firm/any Director of our Company has not been found to be of unsound mind by a Court of competent jurisdiction;
(ii) any partner of our Firm/any Director or our Company has 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;
(iii) any partner or our Firm/any Director of our Company has not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or misrepresentation against an insurer or an insured in the course of any judicial proceedings 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
(iv) any partner of our Firm/any Director of our company is not a minor.
4. It is also declared that the particulars given below are true.
| 1. |
Full name of the applicant (in Block Letters) |
1. |
Company/Firm . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 2. |
Full Address |
2. |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 3. |
The names of all the partners/Directors, with their addresses stating in each case the date of birth and whether the partner/Director claims to |
3. |
. . . . . . . . . . . . . . . . . . . . |
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(a) |
have been in practice as a surveyor/loss assessor on the 26th October, 1968, or |
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(a) |
. . . . . . . . . . . . . . . . |
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(b) |
hold a degree of a recognised university in any branch of engineering, or |
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(b) |
. . . . . . . . . . . . . . . . |
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(c) |
be a fellow or associate member of the Institute of Chartered Accountants of India or Institute of Cost and Works Accountants of India, or |
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(c) |
. . . . . . . . . . . |
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(d) |
possess actuarial qualifications or hold a degree or diploma of any recognized University or institute in relation to insurance, or |
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(d) |
. . . . . . . . . . . |
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73[(e) |
hold a diploma in insurance granted or recognised by the Government, or |
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(e) |
. . . . . . . . . . . . . . . . |
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(f) |
possess any of the technical qualifications mentioned in Rule 56-A. |
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(f) |
. . . . . . . . . . . . . . . . |
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(N.B. In the case of each of the partners/Directors claiming to come under item (a) above and not being eligible to come under any of the items (b) to (f) above, a declaration in the form given in the Annexure to this Form duly filled in and sworn before a Magistrate, Notary Public or Justice of the Peace should be forwarded with this Form and in the case of each of the partners/Directors claiming to come under any one of the items (b) to (f) above, either the original diplomas/certificates with one attested copy each, or copies of the original diplomas/certificates duly attested by a Magistrate, Notary Public or Justice of the Peace should be enclosed. Where original diplomas/certificates are sent, they will be returned after perusal, but no responsibility can be accepted for loss or damage of such originals).] |
(If the space above is insufficient particulars may be given in a separate sheet which should be signed by the applicant) |
| 4. |
Did the Firm/Company ever hold a licence, if so state number and date |
4. . . . . . . . . . . . . . . . . . . . . . . |
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No. . . . . . . . . . . . . . . . Date . . . . . . . . . . . |
| Name of place . . . . . . . . . . . . . . . . . Dated the . . . . . . . . . . . . . . . . . . . . . 20 . |
Yours faithfully, Signature of applicant Designation Name of Firm/Company . . . . . . . . . . . . |
*Strike out portion not required.
(See notes on the reverse)
Annexure
I . . . . . . . . . . . . . . . . . Son/Daughter/Wife of . . . . . . . . . . . . . . . . . hereby declare that on the 26th of October, 1968 I was in practice as a surveyor/loss assessor in respect of general insurance business in my individual capacity/as a partner/Director of (Name of firm).I also declare that I have/the firm has/the company has acted as surveyor/loss assessor and have/has signed a survey/loss assessment report in respect of the following*:
1. Insurance Co.
2. Class of Insurance business.
3. Policy No. and Claim No.
4. Date of report.
Place . . . . . . . . . . . . . . . . .Signature of the applicant
. . . . . . . . . . . . . . . . . . . . . .
The above declaration was sworn before by Mr/Mrs/Miss . . . . . . . . . . . . . who is identified by Mr/Mrs/Miss . . . . . . . . . . . . . . . of . . . . . . . . . . . . . . . who is known to me.
Signature and Seal of Magistrate, Notary Publicor Justice of the Peace.
Place . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . . . . . . . .
*The applicant must give details of a recent survey/loss assessment report signed by him, the Firm/the Company as a surveyor/loss assessor.
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. A firm or company can apply for only one licence which will entitle it to act as a surveyor/loss assessor.
3. Any correction or alteration made in any answer to the questions in the application should be initialled by the applicant.
4. A fee of Rs 250 should be paid into the Reserve Bank of India or where there is no office of the Reserve Bank of India, into the State Bank of India acting as the agent of the Reserve Bank of India or into any Government Treasury for credit under the head XXI Miscellaneous Departments Fees realised under the Insurance Act, 1938 and the receipt shall be sent along with this application.
5. Payment in CASH OR BY MONEY ORDER, CHEQUE, POSTAL ORDER, POSTAGE OR INSURANCE STAMP OR BANK DRAFT, is not accepted and will be returned at applicant's cost.
6. No acknowledgment of the application will be sent. If one is required the application should be sent by a registered post (acknowledgment due).
Not transferable
Form XVIII-AAF
Government of India
(Office of the Controller of Insurance)
LICENCE NO. . . . . . . .
(See Rule 56)
Licence to Act as a Surveyor/Loss Assessor under Part II-B of The Insurance Act, 1938
Name . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . having paid the prescribed fee and having made the necessary declaration is hereby authorized under Section 64-UM of the Insurance Act, 1938 to act as surveyor/loss assessor for five years from . . . . . . . . . . . . . . . . . This Licence will expire on . . . . . . . . . . . . . . . .
| Simla, dated the20 |
Controller of Insurance |
| Seal of the Firm/Company |
(See notes on the reverse) |
Notes
1. If it is desired to renew this licence for a further period, the procedure laid down in Rule 56 of the Insurance Rules, 1939, shall be followed, and an application for renewal should reach the Controller of Insurance at least thirty days before the licence expires.
2. This licence authorises the licence-holder to act as a surveyor/loss assessor for any registered insurer and therefore, no identifying mark or note of any description by which the identity of an insurer might be established should be placed on the licence.
3. No correction in this licence will be valid unless initialled by the Controller of Insurance or a person authorized by him in this behalf.
Form XVIII-AI
Application for a Licence to Act as a Surveyor/Loss Assessor
(See Rule 56)
To
The Controller of Insurance,
Simla-4
Dear Sir,
I request that a licence to act as a surveyor/loss assessor may be granted to me.
2. I enclose the receipt No. . . . . . . . . . dated . . . . . . . . . . . . . . . . . from the . . . . . . . . . showing payment of the fees of Rs 250.
3. I hereby declare that:
(i) I have not been found to be of unsound mind by a Court of competent jurisdiction;
(ii) 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; and
(iii) I have not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or misrepresentation against an insurer or an 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 investigation of the affairs of an insurer;
4. I also declare that the particulars given below are true.
(In block letters)
| 1. |
Full name |
(1) |
*Mr *Mrs. . . . . . . . . . . . . . . . . . . . . *Miss |
| 2. |
*Father's/husband's name |
(2) |
. . . . . . . . . . . . . . . . . . . . . . . . . . |
| 3. 4. 5. |
Full address Date of birth of the applicant in Christian Era. Whether the applicant has been in practice as a Surveyor or loss assessor on the 26th October, 1968 (say Yes or No ) (If the answer is in the affirmative 74[and the applicant is not eligible to come under any of the sub-items (a) to (e) in item 6 below] the declaration in the Annexure to this form should be filled in and duly sworn before a Magistrate, Notary Public or Justice of the Peace.) Qualification: |
(3) (4) (5) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 6. |
75[Whether the applicant possesses any of the following qualifications; if so, give details and also enclose either the original diplomas/certificates with one attested copy each, or copies of the original diplomas/certificates duly attested by a Magistrate, Notary Public or Justice of the Peace. (Where original diplomas/certificates are sent, they will be returned after perusal, but no responsibility can be accepted for loss or damage of such originals).] (The original diplomas/certificates will be returned after perusal) |
(6) |
. . . . . . . . . . . . . . . . . . . . . . . |
| |
(a) |
holds a degree of a recognized University in any branch of engineering; |
|
(a) |
. . . . . . . . . . . . . . . . . . . . . . . |
| |
(b) |
is a fellow or associate member of the Institute of Chartered Accountants of India or the Institute of Cost and Works Accountants of India; |
|
(b) |
. . . . . . . . . . . . . . . . . . . . . . . |
| |
(c) |
possesses actuarial qualifications or holds a degree or diploma of any recognized University or institute in relation to insurance, |
|
(c) |
. . . . . . . . . . . . . . . . . . . . . . . |
| |
(d) |
holds a diploma in insurance granted or recognized by the Government. |
|
(d) |
. . . . . . . . . . . . . . . . . . . . . . . |
| |
76(e) |
possesses any of the technical qualifications mentioned in Rule 56-A.] |
|
(e) |
. . . . . . . . . . . . . . . . . . . . . . . |
| (7) |
Have you ever held a licence? If so, state number and date. |
(7) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . No. . . . . . . . . . . . . . . . . . . . . . . . . Date of issue . . . . . . . . . . . . . . . . . |
*Strike out portion not required.
If the licence is required in the name of sole proprietorship firm, the full name and address of the firm under which the individual carries on or proposes to carry on the work, should also be mentioned here.
This need not be filled up, if answer to (5) is Yes
Yours faithfully,
Signature of the applicant.
Dated the . . . . . . . . . . . . . . . . .
Annexure
I, . . . . . . . . . . . . . . . . ., son/daughter/wife of . . . . . . . . . . . . . hereby declare that on the 26th day of October, 1968, I was in practice as a surveyor/loss assessor in respect of general insurance business. I also declare that I have acted as surveyor/loss assessor and have signed a survey/loss assessment report in respect of the following*
1. Insurance Company.
2. Class of Insurance business.
3. Policy number and Claim number.
4. Date of report.
Place . . . . . . . . . .Signature of the applicant.
Date . . . . . . . . . .
The above declaration was sworn before me by Mr/Mrs/Miss . . . . . . . . . . . who is identified by Mr/Mrs/Miss . . . . . . . . . of . . . . . . . who is known to me.
Signature and Seal of Magistrate, Notary Public or Justice of the Peace.
Place . . . . . . . . .
Date . . . . . . . . .
*The applicant must give details of recent survey/loss assessment report signed by him as a surveyor/loss assessor.
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. An individual can apply for only one licence which will entitle him to act as a surveyor/loss accessor for any insurer.
3. Any correction or alteration made in any answer to the questions in the application should be initialled by the applicant.
4. An applicant must be at least 18 years of age on the date of submission of the application. In the case of an applicant declaring his age as 18 years, the exact date of birth should be given and in all other cases, either the exact date of birth or failing that the year of birth should be stated against Item 4 of the application. If required the applicant shall furnish proof of age.
5. A fee of Rs 250 should be paid into the Reserve Bank of India or where there is no office of the Reserve Bank of India, into the State Bank of India acting as the agent of the Reserve Bank of India or into any Government Treasury for credit under the head XXI Miscellaneous Departments Fees realised under the Insurance Act, 1938 and the receipt shall be sent along with this application.
6. Payment in CASH OR BY MONEY ORDER, CHEQUE, POSTAL ORDER, POSTAGE OR INSURANCE STAMP OR BANK DRAFT is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required, the application should be sent by registered post (acknowledgment due).
Not transferable
Form XVIII-AAI
Government of India
(Office of the Controller of Insurance)
Licence No. . . . . . . . .
(See Rule 56)
Licence to Act as a Surveyor/Loss Assessor under Part II-B Of The Insurance Act, 1938
Mr/Mrs/Miss/. . . . . . . . . . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . .
Working as sole proprietor of . . . . . . . . . . . . . . . . . having paid the prescribed fee and having made the necessary declaration is hereby authorised under Section 64-UM of the Insurance Act, 1938, to act as a Surveyor/Loss Assessor for five years
from . . . . . . . . . . . . . . . . . . . . . . . . This Licence will expire on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Simla, dated the . . . . . . . . . . . . . . . . . . . . . ., 20Controller of Insurance
Signature of licence-holder . . . . . . . . . . . . . . . . .
(Strike out if not required)
(See notes on the reverse)
Notes
1. If it is desired to renew this licence for a further period, the procedure laid down in Rule 56 of the Insurance Rules, 1939, shall be followed and an application for renewal should reach the Controller of Insurance at least thirty days before the licence expires.
2. This licence authorises the licence-holder to act as a surveyor/loss assessor for any registered insurer and, therefore, no identifying mark or note of any description by which the identity of an insurer might be established should be placed on the licence.
3. No correction in this licence will be valid unless initialled by the Controller of Insurance or a person authorized by him in this behalf.
Form XVIII-BF
Application from a Firm or Company for Renewal of a Licence to Act as a Surveyor/Loss Assessor
(See Rule 56)
From
Name of Applicant . .
(In Block Letters)
Full Address . . . . .
. . . . . . . . . . . . . .
. . . . . . . . . . . . . .
(In Block Letters)
To
The Controller of Insurance,
Simla-4.
Licence No. .
Date of expiry . . . . . . . . . . . . . . . . .
Dear Sir,
It is requested that the above licence may be renewed for a further period of five years.
2. Receipt No. . . . . . . ., dated . . . . . . . . . from the . . . . . . . . showing payment of Rs 200 is enclosed.
3. *It is hereby declared that . . . . . . . . . . . . .
(i) any partner of our Firm/any Director of our Company has not been found to be of unsound mind by a Court of competent jurisdiction;
(ii) any partner of our firm/any Director of our Company has 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;
(iii) any partner of our Firm/any Director of our Company has not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or misrepresentation against an insurer or an 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
(iv) any partner of our Firm/any Director of our Company is not a minor.
4. It is declared that each one of the partners/Director of the firm who was a partner/Director when the above-mentioned licence was issued and who is now a partner/Director continues to satisfy the requirements of clause (D) of sub-section (1) of Section 64-UM of the Act.
5. It is also declared that the particulars given below are true.
6. The name of all the partners/Directors, with their addresses, are given below, stating in each case the date of birth and whether the partner or Director claims to. . . . .
| (a) |
have been in practice as a surveyor/loss assessor on the 26th October, 1968, or |
(a) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| (b) |
hold a degree of a recognised University in any branch of engineering, or |
(b) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| (c) |
be a fellow or associate member of the Institute of Chartered Accountants of India or Institute of Cost and Works Accountants of India, or |
(c) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| (d) |
possess actuarial qualifications or hold a degree or diploma of any recognised University or Institute in relation to Insurance, or |
(d) |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 77[(e) |
hold a diploma in insurance granted or recognised by the Government, or |
|
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| (f) |
possess any of the technical qualifications mentioned in Rule 56-A; |
|
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
(N.B. In the case of each of the partners/Directors who was not a partner/Director on the date of last application for licence
(i) where he claims to come under item (a) above and is not eligible to come under any of the items (b) to (f) above, a declaration in the form given in the Annexure to this Form duly filled in and sworn before a Magistrate, Notary Public or Justice of the Peace should be forwarded with this Form; and
(ii) where he claims to come under any one of the items (b) to (f) above, either the original diplomas/certificates with one attested copy each, or copies of the original diplomas/certificates duly attested by a Magistrate, Notary Public or Justice of the Peace should be enclosed. Where original diplomas/certificates are sent, they will be returned after perusal, but no responsibility can be accepted for loss or damage of such originals.)]
Yours faithfully,
Dated the . . . . . . . . . ., 20
Signature of the applicant.
Designation . . . . . . . . .
Name of Firm/Company . . . . . . . . . . . .
*Strike out portions not required.
(See notes on the reverse)
Annexure
I, . . . . . . . . . . . . . . . . ., son/daughter/wife of . . . . . . . . . . . . . . . . ., hereby declare that on the 26th day of October, 1968, I was in practice as surveyor/loss assessor in respect of general insurance business in my individual capacity as a partner/Director of . . . . . . . . . . . . . . . . . (name of firm). I also declare that I have/the firm has/the company has acted as surveyor/loss assessor and have/has signed a survey/loss assessment report as surveyor/loss assessor in respect of the following*:
1. Insurance Company.
2. Class of Insurance business.
3. Policy No. and Claim No.
4. Date of report.
Signature of the applicant.
Place . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . . . . . . . .
The above declaration was shown before me by Mr/Mrs/Miss . . . . . . . . . . who is identified by Mr/Mrs/Miss . . . . . . . . . . . . . . of . . . . . . . . . . . . . . . who is known to me.
Place . . . . . . . . . . . .Signature and Seal of Magistrate, Notary
Date . . . . . . . . . . . .Public Justice of the Peace.
*The applicant must give details of a recent survey/loss assessment report signed by him/the firm/the company as a surveyor/loss assessor.
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. The name and the licence number given in the application should be identical with those shown in the licence held. If there is any subsequent change in the name, the reasons for the same should be stated furnishing documentary evidence for the same.
3. Any correction or alteration made in the application should be initialled by the applicant.
4. The application should reach the Controller of Insurance at least thirty days before the expiry of the licence held by the applicant. If the application does not reach the Controller of Insurance at least 30 days before the date on which the licence ceases to be in force, it will not be entertained. In that case the applicant, if he so desires, may apply for a fresh licence by paying a fee of Rs 250.
5. A fee of Rs 200 should be paid into the Reserve Bank of India or where there is no office of the Reserve Bank of India, into the State Bank of India acting as the agent of the Reserve Bank of India or into any Government Treasury for credit under the head XXI Miscellaneous Departments Fees realised under the Insurance Act, 1938 and the receipt shall be sent along with this application.
6. Payment in CASH OR BY MONEY ORDER, CHEQUE, POSTAL ORDER, POSTAGE OR INSURANCE STAMP OR DRAFT is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required the application should be sent by registered post (acknowledgment due).
Not transferable
Form XVIII-BBF
(Office of the Controller of Insurance)
Licence No. . . . . . . . . . .
(See Rule 56)
Renewal of Licence to Act as Surveyor/Loss Assessorunder Part II-B of the Insurance Act, 1938
Name . . . . . . . . . . . . . . .
Address. . . . . . . . . . . . . .
having paid the prescribed fee and having made the necessary declaration, its licence No. . . . . . . . ., dated . . . . . . . . . . . to act as surveyor/loss assessor is hereby renewed up to the . . . . . . . ., day of . . . . . . . . . ., 20.
Simla, dated the . . . . . . . . . . ., 20.Controller of Insurance
Seal of the Firm/Company.
Notes
1. If it is desired to renew the licence for a further period, the procedure laid down in Rule 56 of the Insurance Rules, 1939, shall be followed, and an application for renewal should reach the Controller of Insurance at last thirty days before the licence expires.
2. The Licence authorises the licence-holder to act as a surveyor/loss assessor for any registered insurer and therefore, no identifying mark or note of any description by which the identity of an insurer might be established should be placed on the licence or on this renewal licence.
3. No correction on this renewal licence will be valid unless initialled by the Controller of Insurance or a person authorised by him in this behalf.
Form XVIII-BI
Application for Renewal of a Licence to Act as a Surveyor/Loss Assessor
(See Rule 56)
From
Name of Surveyor/Mr*
Loss AssessorMrs*
Miss*
Full Address . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
To working as sole proprietor of . . . . . . . . . . . . . . .
The Controller of Insurance,
Simla.
Licence No. . . . . . . . . .
Date of expiry . . . . . . .
Dear Sir,
I request that the above licence may be renewed for a further period of five years.
2. I enclose receipt No. . . . . . . . . . . . . . . . . . ., dated . . . . . . . . . . . ., from the . . . . . . . . . . . . . . . . . . showing the payment of Rs 200.
*3. I declare that since the date of my last application for a licence:
(i) I have not been found to be of unsound mind by a court of competent jurisdiction;
(ii) 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;
(iii) I have not been found guilty of or to have knowingly participated in or connived at any fraud, dishonesty or misrepresentation against an insurer or an 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 any investigation into the affairs of an insurer; and
(iv) my licence has not been cancelled at any time by the Controller of Insurance;
(v) I declare that I continue to hold the qualification on the basis of which my licence mentioned above was issued.
4. I also declare that the facts stated herein are true.
Yours faithfully,
Dated the . . . . . . . ., 20Signature of the applicant.
*Strike out whichever is not applicable.
Strike out if not applicable.
Notes
1. The attention of the applicant is drawn to Section 104 of the Insurance Act, 1938, which provides that whoever in any document required for the purposes of any of the provisions of that Act, wilfully makes a statement false in any material particular, knowing it to be false, shall be punishable with imprisonment for a term which may extend to three years, or with fine which may extend to one thousand rupees, or with both.
2. The name and the licence number given in the application should be identical with those shown in the licence held. If there is any subsequent change in the name, the reasons for the same should be stated furnishing documentary evidence for the same.
3. Any correction or alteration made in the application should be initialled by the applicant.
4. The application should reach the Controller of Insurance at least thirty days before the expiry of the licence. If the application does not reach the Controller of Insurance at least 30 days before the date on which the licence ceases to be in force, it will not be entertained. In that case the applicant, if he so desires, may apply for a fresh licence by paying a fee of Rs 250.
5. A fee of Rs 200 should be paid into the Reserve Bank of India or where there is no office of the Reserve Bank of India into the State Bank of India acting as the agent of the Reserve Bank of India or into any Government Treasury for credit under the head XXI Miscellaneous Departments Fees realised under the Insurance Act, 1938 and the receipt shall be sent along with the application.
6. Payment in CASH OR BY MONEY ORDER, CHEQUE, POSTAL ORDER, POSTAGE OR INSURANCE STAMP OR BANK DRAFT is not accepted and will be returned at applicant's cost.
7. No acknowledgment of this application will be sent. If one is required the application should be sent by registered post (acknowledgment due).
Form XVIII-BBI
GOVERNMENT OF INDIA
(Office of the Controller of Insurance)
Licence No. . . . . . . . . .
(See Rule 56)
Renewal of Licence to Act as Surveyor/Loss Assessor under Part II-B of the Insurance Act, 1938
Mr.
Mrs . . . . . . . . . . . . .
Miss
Address. . . . . . . . . . . .
. . . . . . . . . . . . .
Working as sole proprietor ofhaving paid the prescribed fee and having made the necessary declaration his/her licence No. . . . . . . . ., dated. . . . . . . . ., to act as a surveyor/loss assessor is hereby renewed up to . . . . . . . . . day of. . . . . . . . . . . . . . . . . ., 20
Simla, dated the . . . . . . . . . . . . .. . . . ., 20Controller of Insurance.
Signature of licence holder . . . . . . . . . . . . . .
Strike out if not required.
(See Notes on the Reverse)
1. If it is desired to renew the licence for a further period, the procedure laid down in Rule 56 of the Insurance Rules, 1939, shall be followed, and an application for renewal should reach the Controller of Insurance at least thirty days before the licence expires.
2. The licence authorises the licence-holder to act as a surveyor/loss assessor for any registered insurer and therefore, no identifying mark or note of any description by which the identity of an insurer might be established should be placed on the licence or on this renewal licence.
3. No correction in this renewal licence will be valid unless initialled by the Controller of Insurance or a person authorised by him in this behalf.]
SCHEDULE II
(See Rule 43)
[* * *]78