Insurance Brokers Association of India

INSURANCE BROKERS ASSOCIATION OF INDIA

Registered office; Unit No.165, A to Z Industrial Premises Co – Operative Soc. Ltd., G.K. Marg,

Lower Parel (W) Mumbai – 400 013, Tel.No.022 -24955156, E-mail :

I/WE WISH TO BECOME MEMBER OF THE ASSOCIATION AND AGREE TO ABIDE BY ITS RULES AND REGULATIONS IN FORCE NOW OR WHICH MAY BECOME APPLICABLE IN FUTURE.

1. / NAME OF THE APPLICANT (Broking Firm)
REGISTERED OFFICE ADDRESS
TELEPHONE
FAX
E MAIL
DATE OF INCORPORATION
IRDA LICENSE CODE NO & VALIDITY PERIOD OF LICENSE:
( ENCLOSE COPY)
HAVE YOU PAID ANNUAL LICENSE FEE OF IRDA UP TO DATE.
2. / WHETHER INDIVIDUAL, PARTNERSHIP/PVT/PUBLIC LTD COMPANY
3. / NAME OF THE PARTNER/PROMOTES/DIRECTORS
WITH QUALIFICATIONS
4. / HAVE YOU BEEN WORKING AS AN AGENT OR EMPLOYEE OF LIC OR ANY OF THE GENERAL INSURANCE COMPANIES, IS SO HOW LONG.
5. / IS YOUR OFFICE ACCOMMODATION OWNED/LEASED.
6. / DO YOU EMPLOY STAFF, PLEASE GIVE NAMES OF KEY EMPLOYEES AND THEIR QUALIFICATIONS
7. / NAMES OF YOUR BANKERS
8. / IS YOUR COMPANY INVOLVED IN REINSURANCE BROKING.
9. / DO YOU REPRESENT ANY OVERSEAS BROKERS.
10. / ANY OTHER RELEVANT INFORMATION

I/WE DECLARE THAT THE UNDERSIGNED AND/OR PARTNERS AND/OR DIRECTORS OF THE ABOVE APPLICANT HAVE NOT BEEN CONVICTED OF ANY OFFENCE.

NAME OF THE PRINCIPAL OFFICER______.

SIGNATURE OF PRINCIPAL OFFICER______(PUT CO. RUBBER STAMP)

PLACE:

Date:

MEMBERSHIP FEES:** Direct Broker … Rs. 15,000/- per annum.

Reinsurance Broker ..Rs. 35,000/- per annum. - Composite Broker … Rs. 50,000/- per annum.

RENEWABLE ANNUALLY.

Kindly attach copy of your IRDA license as well as your DD/ Cheque for Annual Membership fees in favour of

“Insurance Brokers Association of India”.

**Membership Fees are to be paid proportionately from the month of joining till the close of financial year in next March. For example, if membership is taken in August 2017, membership fee is to be paid proportionately for 8 months from August 2017 to March 2018, which will work out to Rs.10,000/- for a Direct Broker, Rs.23,333/- for Re-insurance Broker and Rs.33,333/- for Composite Broker. Plus applicable GSTrates, which is 18%