TaxTMI 
TaxTMI 
Application Form and documents required
X X X X Extracts X X X X
X X X X Extracts X X X X
....spects. 4. Information which needs to be supplied in more details may be given on separate sheets which should be attached to the application form. 5. If the applicant is not a company, the information called for in this Form shall be supplied by adapting the requirements suitably. 1. PARTICULARS OF THE APPLICANT 1.1 Name of the Applicant : _________________________ 1.2 (A) Address - Principal Place of business / Registered Office. ___________________________________________ ___________________________________________ Pin/Zip code: ____________________ Telephone No: ______________ E-mail: ________________ Fax No: --------------------- (B) Address for Correspondence: ___________________________________________ _____________________________________________ Pin/Zip code: ____________________ Telephone No: ________________ E-mail: _________________ Fax No: ______________ C) Address of Branch Office: _____________________________________________ Details of the proposed/existing branch office(s) where applicant proposes to distribute insurance....
X X X X Extracts X X X X
X X X X Extracts X X X X
....No. or Passport no (Individual)/National Id No./ PAN No (entities) 2.6 Whether any of the associate company of applicant is interested in the applicant's business? If yes, give following details of associate companies Name of Company/ Firm Address Type of activity handled Nature of Interest of Promoters/Directors Nature and interest of applicant company 2.7 Name and Address of the Principal bankers of the applicant 2.8 Name and address of the statutory auditors: 3. BUSINESS INFORMATION 3.1 Three years business plan document with projected volume of activities and income for which registration sought is to be specifically given. 3.2 Organization Chart separately showing functional responsibilities to be enclosed. 3.3 Particulars of Key Management Personnel (Not applicable for Corporate Agent) Name Address & contact details Qualification Experience in Insurance ....
X X X X Extracts X X X X
X X X X Extracts X X X X
....vestments, Loans & Advances made to Associate Companies/Firms where Promoters/Directors have an interest is to be separately given). 4.4 Income and Profit before Tax (PBT) (in USD in million) (Not applicable for Corporate Agent) Particulars Income and Profit Before Tax FY prior to the preceding year of current year FY of Preceding year FY of Current year 4.5 Dividend (in USD in million) (Not applicable for Corporate Agent) Particulars FY prior to the preceding year of current year FY of Preceding year F....
X X X X Extracts X X X X
X X X X Extracts X X X X
....sidered relevant for the purposes of our registration. c. We declare that the information supplied in the application form is complete and correct. d. We undertake that we shall not allow or offer to allow, either directly or indirectly, as an inducement to any person, any rebate of the whole or part of the remuneration or reward earned by us during the registration period. e. We undertake to service the run-off business on the books at the time of cancellation or non-renewal of registration subject to the applicable norms. For and on behalf of _____________________ _____________________ (Signature & Name) (Signature & Name) {Block Letters} {Block Letters} Director Director Name of the Applicant Name of the Applicant Place: Place: Date: Date: ___________________________________________________________________________ Particulars of Principal Officer/Branch Head/Directors/Partners/Promoters/ Key Management Personnel (This form shall be filed separately for each KMP) Personal details of Principal Officer/ Directors/ Partners/ Promoters/ Key Management Personnel Full Name Mention ....
X X X X Extracts X X X X
X X X X Extracts X X X X
....egistration Submission of Completed Application. a) Submission of relevant information as required in the Application form. b) Remittance of requisite fee as per category of insurance intermediary as specified by the Authority. c) Submission of printed copy of applicant's Memorandum and Articles of Association/Partnership deed or its equivalent d) Submission of printed copy of certificate of incorporation issued by Registrar of companies, if applicable. e) Undertaking for ensuring compliance of the training requirements as specified in these regulations within three (3) months from the date of grant of Certificate of registration. f) Particulars of Principal Officer/Branch head/Directors/Partners/Specified person/Broker Qualified person/KMP as mentioned in this schedule along with the FIT and Proper criteria format as specified by Authority. g) Board resolution in support of filing of the application and person authorized to sign the application. h) Principal Officer to submit a declaration that the applicant (directors/partners, principal officer and key management personnel of the company) are not sufferin....
X X X X Extracts X X X X
X X X X Extracts X X X X
....G FRESH/RENEWAL CERTIFICATE OF REGISTRATION BY AN INSURANCE INTERMEDIARY FOR ESTABLISHING IIIO IN THE FORM OF BRANCH S.No. Particulars Applicant's Response Remarks Section A : Company Profile 1 Name of the applicant 2 Registered office address 3 Date of incorporation: [DD/MM/YYYY] Certificate of incorporation/Deed of Covenant/Other valid proof 4 Registration No. (issued by the regulatory Authority in the country of the applicant's domicile, if any) and date of first registration [DD/MM/YYYY] Copy of the registration certificate 5 Current lines of insurance intermediary a. Broker-Direct/Composite/Reinsurance b. Corporate Agent c. Third Party Surveyor d. Surveyor and loss assessor 6 Amount of Authorised capital, Subscribed capital and Issued Capital & Face value of shares and their numbers/ Total contribution by partners/members and individual contribution by each partner/member 7 Name, Address and contact details of the person responsible for the affairs of the proposed IIIO and furth....
X X X X Extracts X X X X
X X X X Extracts X X X X
....areholders of insurance intermediary: [Please give full name, address, percentage of holding in the paid up capital of the intermediary, Occupation, Qualifications and Experience, Number of shares held and Percentage of share capital in the company] Please attach separate sheets if necessary. Details of persons holding more than 1% of the issued capital of the applicant and promoters are to be given in separate statements. Full Name [first, middle, surname]/Name of the Corporate Date of Birth/Date of incorporation Address with Telephone Nos., Fax Nos., E-mail Qualifications * Experience * Present occupation * No. of equity (voting rights) shares and percentage of total holding Remarks (1) (2) (3) (4) (5) (6) (7) (8) Mr./Ms. *Columns 4 to 6 may be left blank for corporate shareholders. Section B: Regulatory Compliance in the home country 20 Name, Address and contact details of the Regulatory Aut....