Distributor Empanelment Form

(Application Form must be filled in BLOCK LETTERS in English)

Name : Mr / Ms / M/s Name as mentioned on ARN Card / Certificate

Address in full :

City : State : Pin:

Tel no . Fax: Mobile No.:

E-mail Id :

Date of Birth / Incorporation ( DD / MM / YYYY)

ARN valid upto (DD/MM/YYYY)

PAN

For Individual :
Educational Qualification
Occupation : Service Business Housewife Retired others

For Non - Individual :

Status : Company Bank Partnership Firm Trust Proprietary Firm Others (Specify)

Name of Proprietor / Key Person : Telephone :

Contact Person(s) Telephone :

Bank details :
Bank Name Branch
Address:
City Pin:

A/c Type : Savings Current NRO NRE

Core Banking A/c No.

A/c no in words

IFSC Code (11 digits)

MICR Code

Note: Please provide the complete Core Banking Solution (CBS) account number and 11 digit alpha numeric IFSC code. Also
attach copy of the cancelled cheque for the above mentioned A/c number, to issue the payout through NEFT/RTGS.
 Total Experience ( no of years)
Client Profile:
HNI Retail Corporate

Others
Reach / Network :
Local Regional All India
Type of MF products you offer to the client :
Cash fund Debt fund Equity fund MIPs All
Business procured for other MFs in the past three years:
Organisation Rs. in Lacs (Year 1) Rs. in Lacs (Year 2) Rs. in Lacs (Year 3)

Relevant document(s) submitted : Yes No ( please check documents list mentioned at pt 12 in terms & conditions)
Declaration:
This is to certify that is a partnership / corporate / proprietorship firm and all employees engaged
in sales and distribution activities are AMFI certified and also have applied for / received their ARN photo ID cards.
“I will comply with the provisions of The Prevention of Money Laundering Act, 2002 guidelines issued by Securities and Exchange
Board of India and association of Mutual Funds in India from time to time in this regards.”

Place :
Date :

(Signature of the Applicant)

DISTIRBUTOR EMPANELMENT - CHECKLIST
MANDATORY FOR NON INDIVIDUALS /CORPORATE DISTRIBUTORS
 Empanelment Form duly filled (With Photo of Contact/Authorised Person)
 Copy of PAN Card
 Copy of ARN Card
 Copy of AMFI / NISM Certificate
 Certified true copy of Partnership Deed (In case of a Partnership Firm)
 Certified true copy of Memorandum & Articles of Association (In case of a company)
 Certified true copy of Resolution of Firm / Company and Authorized Signatory List
 Bank Account Details of Distributor - Bank Name / Branch / Number
 Copy of cancelled cheque
 KYD Acknowledgement
 It is mandatory to submit "List of Sales Persons/Employees with EUIN

MANDATORY FOR INDIVIDUALS KARTA OF HUF / SOLE PROPRIETORSHIP

 Empanelment Form (With Photo & Effective date of empanelment)
 Copy of PAN Card
 Copy of ARN Card
 Copy of AMFI / NISM Certificate
 Bank Account Details of Distributor - Bank Name / Branch / Number
 Copy of cancelled cheque
 KYD Acknowledgement
 It is mandatory to submit "List of Sales Persons/Employees with EUIN
 “All employees engaged in sales and marketing activities should obtain AMFI certification. Employees in other functional areas should also be encouraged
to obtain the same certification."
 TERMS AND CONDITIONS
1. A distributor shall carry out such directions and instructions as may, from time to time, be issued by LIC Mutual Fund Asset Management
Ltd. (AMC) in this regard.
2. A distributor /or its employee who are involved in distribution of MF products must have cleared the AMFI / NISM certification test. A self
attested copy of ARN card / AMFI certificate & PAN card must be submitted by the distributor to LIC Mutual Fund Asset Management Ltd.,
for its records and verification.
3. A distributor is not authorised to issue any receipt for cheques and demand drafts received along with the application forms on behalf of the
AMC. The distributor shall at no point of time receive cash on behalf of the AMC.
4. A distributor is eligible for brokerage on the amounts mobilized by him at the rate(s) prescribed by AMC. The rate(s) are subject to revision,
from time to time, at the discretion of the AMC and the distributor shall be bound by such changes. The brokerage payable shall be
inclusive of any tax, service tax, cost, charges and expenses incurred by the Distributor in connection with the agency.

5. The Distributor declares and covenants with the AMC to defend, indemnify and hold the AMC and its affiliates, promoters, successors in
interest and permitted assigns harmless from and against all claims, damages or assertions of liability of any kind or nature resulting from:
a) any breach of terms, covenants and conditions or other provisions hereof, or SID(s) or any actions or omissions there under;
b) any failure to comply with all applicable legislation, statutes, ordinances, regulations, administrative rulings or requirements of law;
c) the misfeasance, malfeasance or fraudulent acts of the representatives of the Distributors; and
d) any and all actions, suits, proceedings, assessments, settlement, arbitration judgments, cost and expenses, including attorneys’ fees,
resulting from any of the matters set forth above.
6. The appointment of a distributor shall be liable to be terminated by the AMC forthwith:
a) If he/she is found to be a minor or adjudicated as an insolvent or found to be of unsound mind by a court of competent jurisdiction;
b) If in course of any judicial proceeding it is found that he/she has knowingly participated in or connived at any fraud, dishonesty or
misrepresentation against the AMC or any Unit holder of LIC Mutual Fund
c) If the AMC is satisfied that any statement made in the Distributor Registration Form was false or misleading or calculated to mislead;
d) If he / she acts in any other manner prejudicial to the interest of the AMC / Mutual Fund; and
e) If he / she does not comply with all applicable legislation, statutes, ordinances, regulations, administrative rulings or requirements of
law.
f) If he / she fails to comply with the terms and conditions mentioned in this empanelment form.
7. In addition to what is stated in the preceding paragraphs the AMC shall have the right to terminate the appointment of Distributor at any
time by giving the Distributor 30 days notice and assigning any reasons thereof. A distributor may also terminate the agency at any time
by giving 30 days notice to the AMC.
8. A distributor shall not have any claim against the AMC/Mutual Fund for any loss incurred by him/her as not anticipated and arising out of
any revision in the rate(s) of commission for business canvassed.
9. A distributor must read and understand the SID of the respective scheme(s) carefully and explain the risks, investment objectives and
the special features of the schemes to the investors. The Distributor must not make any representation concerning Units or the Mutual
Fund except those contained in the SID of the respective scheme(s), the Key Information Memorandum containing Application Forms and
printed information issued by the AMC as information supplemental to such documents.

10. The Distributor must not use any unethical means to sell, market or induce any investor to buy Units of LIC Mutual Fund..
11. In case of application by non-individuals, a certified true copy of the relevant Board resolution or authority to make the application as the
case may be, along with a certified true copy of the MOA/Partnership deed/ Certification of registration / Authorised Signatories list should
be submitted. A declaration on company letter head for the employees engaged in sales activity should be submitted.
12. The Distributor shall use only such SIDs, Key Information Memorandum containing Application Forms and advertising material provided by
AMC and the Distributor shall not design its own advertisement of the scheme(s) of LIC Mutual Fund unless it has obtained prior approval
in writing from the AMC.
13. The agency shall stand automatically terminated without any notice from the AMC / Mutual Fund upon disqualification or withdrawal of
Regulatory or Government Approval to act in the capacity contemplated herein. Upon any termination, the Distributor shall forthwith
return all documents, papers and material pertaining to AMC / Mutual Fund and / or belonging to AMC / Mutual Fund to the AMC.
14. Appointment as a distributor is subject to written confirmation by LIC Mutual Fund Asset Management Ltd.
15. In respect of all disputes arising under this empanelment, the courts in Mumbai alone shall have jurisdiction.
16. The Distributor shall comply with the provisions of the Securities and Exchange Board of India (Mutual Funds) Regulations, 1996 and
guidelines issued by SEBI/AMFI Form time to time pertaining to mutual funds with specific focus on regulations/guidelines on
advertisements / sales literature and code of conduct for distributors and shall adhere to it at all times.