NIPPON LIFE Application No.

EA10387430
INSURANCE (Please note this application no. for your record)

Agent Recruitment Form Associate Business Partner* Yes No

Client Number 22754429
Advisor Code No. 22754429
Notes and Instructions
1. The application should be filled in English language. 2. Any correction or alteration made in any answer to the questions
in the application should be initialed by the applicant. 3.An applicant must be at least 18 years of age on the date of the
application. The applicant shall furnish proof of age. 4. An applicant shall furnish the proof of pass in the pre-recruitment
exam conducted by an examination body duly recognized by the Insurance Regulatory and Development Authority of
India. 5. The following documents should be attached with the application. a. Age Proof (Self-attested) b. Educational
Qualification (Self-attested) c. Proof of Pass in the agency examination as mentioned above d. Copy of PAN Card (Self-
attested) e. Address Proof (Self-attested).
*These are only Agents and identified as probable MDRT or high performing agents.

For your careful consideration: a) All the questions are to be answered in detail. b) Your appointment is subject to the provisions of Guidelines on
Appointment of Insurance Agent, 2015 issued by IRDAI.

SM/CDA Code 295767 Sales Unit Code 0485SU01AGAG

SM/CDA Name ABBA NITHIMA
CSC Branch Location 103004850485SU01
1. a. Name in full Mr./Mrs./Miss. Mr.Piyush kumar Raja
b. Father’s/Husband’s Name Paresh kumar raja
c. Gender Male Female d. Date of Birth 21-11-2003 e. Marital Status Single Married Divorced
f. Nationality INDIAN
g. Nominee Name Paresh Kumar Raja
Relationship Age 21
h. Bank Name
(Attach a copy of cancelled cheque for all banks except ICICI/HDFC Bank)
Account No
Bank Branch
i. PAN Card No FRWPR2054F (Attach self-attested copy of PAN card)
j. Aadhar Card Number (Non Mandatory) (Attach self-attested copy of Aadhar Card )
k. GSTIN No. (if any) (Attach self-attested copy of GSTIN Registration Certificate)
l. Reliance Nippon Life Branch Name .. Nizamabad
m. Location of the Candidate Rural Urban
n. Family Income: >2 - lacs Income Proof list: Latest ITR Salary Slip Form 16 CA certificate Pension Orders

Mandi receipts with 7/12 Bank Statements of last 3 months Appointment letter Employer certificate Others OR CH approval

2. Address (in Block Letters)

*a. Present 7-1-39, Mahalaxmi residency ,marwadi gally, Kanteshwar S.O, Nizamabad, TELANGANA, India, 503002

b. Permanent 7-1-39, Mahalaxmi residency ,marwadi gally, Kanteshwar S.O, Nizamabad, TELANGANA, India, 503002

3. Telephone (O) Fax

Telephone (R) Mob 9390880273
Email Address piyushraja61@gmail.com
4. Education Qualification (Tick the highest qualification) Class X Class XII Graduate Post Graduate Associate/Fellowship

Associate/Fellowship of CA Associate/Fellowship of ICWAI Associate/Fellowship of CS Associate/Fellowship of Actuarial Society of India

MBA Others

Basic Qualification Details Class X Class XII Board Name Borad of secondary school
Roll No. 2005106474 Year of Passing Mar 2020 5. Category General SC ST OBC
6. Primary Profession
 Application No. EA10387430
(Please note this application no. for your record)
7. Employment Record (Beginning with your present employment, list all positions held over last 3 employments)
From To Name and Address of Employer Last Position Held Annual Income Reason for Leaving

OTHERS

8. Furnish the details of any insurance agency in force or ever held by the applicant

Name of the Insurer Agency Code Number Date of Appointment as Agent Date of Cessation of Agency Reason for Cessation of Agency

*Please attach Agency cessation letter issued by the insurer

9. Please give two References (Mandatory)

Name and Address (1) Name and Address (2)

Phone No. Phone No.

Q Score Questionnaire – Mandatory (Please tick the correct box as applicable)

Sr.No. Criteria

1 Age 18-25 years >25-40 years >40 years

2 Number of years residing in current city 0-2 years >2-5 years >5 years
3 Education Qualification Class 12 Graduation Post Graduation/Professional

4 Family Income 0-2 Lakhs >2-4 Lakhs >4 Lakhs

5 Marital Status Unmarried Married
6 Association with Esteemed Clubs (Lions, Rotary,etc.) No Yes
7 Preferred Profiles No Yes (if yes, kindly provide relevant proof
8 Has 2-wheeler/4-wheeler No 2-wheeler 4-wheeler
9 Has previous sales experience No Yes
*Preferred Profiles

Teacher/Professor, State & Central Govt Employees, Bank Employees, Post Master/Postal Employees/Postal Agent, Financial Product Distributors
(MF/FD/Bonds/Home Loans/Gen. Ins./Chit Funds/Daily Deposits), FMCG Distributors/Network Agents, (Amway/Tupperware/Modicare/Oriflame/
Sahara/Avon/Forever Life/Herbalife Agents), Army/Navy/Airforce/Police Personnel, Panchayat Pradhan/Panchayat Secretary, Retired Persons/Retired
Development Officers, Doctors, Medical practitioners(nurses, lab technicians), Chemists, Lawyers, CA/CS/Tax Consultants/Accountants, Travel Agents/RTO
Agent/Real Estate Agent, Kirana Shop Owners/PDS Shopkeepers(Ration Shop Owners), Anganwadi Workers/Women in SHG Members of
Business/Registered Communities/Clubs (Rotary Club/Lions Club/Puja Committee etc.)

The TM has to verify all the documents for criteria mentioned in Q Score in original and sign on the form “verified”
10. Particulars of pass in pre-recruitment test conducted by the Insurance Institute of India or any Examination Body:

Name of Examination Body

Candidate’s Name Piyush kumar Raja
Candidate’s Number
Centre of Examination NSEiT Limited - NIZAMABAD Exam Language ENGLISH
Name of the Exam passed Insurance Institute of India
Date of Passing

11. Details of other insurance related activities undertaken, if any

 Application No. EA10387430
(Please note this application no. for your record)
Not applicable for Application login through online mode

Selected Rejected
The following enclosures are attached with the Agent Recruitment Form:
For branch office use only

Education Proof Photographs (2 nos.)

Reference Agent Code: Reference Agent Name:

SELECTED BY: VERIFIED & APPROVED BY:
SM Name ABBA NITHIMA BM Name Akkampally Radhakishan
SAP Code 70659111 SAP Code 70311308

Signature Date 09-12-2024 Signature Date 09-12-2024

12. Code of Conduct Confidential and for internal communication only.

(i) Every insurance agent shall,
(a) identify himself and the insurance company of whom he is an insurance agent;
(b) show the agency identity card to the prospect, and also disclose his agency appointment letter to the prospect on demand;
(c) disseminate the requisite information in respect of insurance products offered for sale by his insurer and take into account the needs of the prospect while recommending a
specific insurance plan;
(d) where the Insurance agent represents more than one insurance company offering same line of products, he should dispassionately advice the policyholder on the products
of all Insurers whom he is representing and the product best suited to the specific needs of the prospect;
(e) disclose the scales of commission in respect of the insurance product offered for sale, if asked by the prospect;
(f) indicate the premium to be charged by the insurer for the insurance product offered for sale;

(g) explain to the prospect the nature of information required in the proposal form by the insurer, and also the importance of disclosure of material information in the purchase
of an insurance contract;
(h) bring to the notice of the insurer any adverse habits or income inconsistency of the prospect, in the form of a report called “Insurance Agent’s Confidential Report” along
with every proposal submitted to the insurer, and any material fact that may adversely affect the underwriting decision of the insurer as regards acceptance of the
proposal,by making all reasonable enquiries about the prospect;
(i) obtain the requisite documents at the time of filing the proposal form with the insurer; and other documents subsequently asked for by the insurer for completion of the
proposal;
(j) advise every prospect to effect nomination under the policy;
(k) inform promptly the prospect about the acceptance or rejection of the proposal by the insurer;
(l) render necessary assistance and advice to every policyholder on all policy servicing matters including assignment of policy, change of address or exercise of options under
the policy or any other policy service, wherever necessary;
(m) render necessary assistance to the policyholders or claimants or beneficiaries in complying with the requirements for settlement of claims by the insurer;
(ii) No insurance agent shall,
(a) solicit or procure insurance business without being appointed to act as such by the insurer

(b) induce the prospect to omit any material information in the proposal form;
(c) induce the prospect to submit wrong information in the proposal form or documents submitted to the insurer for acceptance of the proposal;
(d) resort to multilevel marketing for soliciting and procuring insurance policies and/or induct any prospect/policyholder to join a multilevel level marketing scheme;
(e) behave in a discourteous manner with the prospect;
(f) interfere with any proposal introduced by any other insurance agent;
(g) offer different rates, advantages, terms and conditions other than those offered by his insurer;
(h) demand or receive a share of proceeds from the beneficiary under an insurance contract;
(i) force a policyholder to terminate the existing policy and to effect a new policy from him within three years from the date of such termination of the earlier policy;
(j) apply for fresh agency appointment to act as an insurance agent, if his agency appointment was earlier cancelled by the designated official, and a period of five years has
not elapsed from the date of such cancellation;
(k) become or remain a director of any insurance company;
(iii) Every insurance agent shall, with a view to conserve the insurance business already procured through him, make every attempt to ensure remittance of the
premiums by the policyholders within the stipulated time, by giving notice to the policyholder orally and in writing;
14. I request that Appointment to act as an insurance agent of your organisation may be granted to me.
I do hereby declare that the foregoing statements and answers are to the best of my knowledge and belief, true and complete and that they shall be the basis of Contract of
the Agency between me and the Reliance Nippon Life Insurance Company Limited and that if any of the foregoing statements or answers are untrue or incomplete the said
Contract shall automatically terminated from the date on which such knowledge comes to the Company.
I hereby confirm that this Agency Application Form has been completed by me in my own handwriting
I agree to abide by the terms and conditions as laid down in various Regulations and Acts applicable to working as an Advisor of Reliance Nippon Life Insurance Company
I 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;
iii) I have not been found guilty of or to have knowingly participated in or connived at any fraud, dishonestly or mis-representation against an insurer or an insured.
iv) The Agent is responsible for updating his registration status under GST to RNLIC
Mktg/Insurance Agency Form/Version2.3/Apr 2019

Yours faithfully,
Date 09-12-2024 Place Nizamabad Signature

This is auto generated application form and doesnot required signature of applicant
Reliance Nippon Life Insurance Company Limited. IRDAI Registration No: 121. Registered & Corporate Office: Unit Nos. 401B, 402, 403 & 404, 4th Floor, Inspire-BKC, G
Block, BKC Main Road, Bandra Kurla Complex, Bandra East, Mumbai - 400051. India. T +91 22 6896 5000. Trade logo displayed above belongs to Anil Dhirubhai Ambani
Ventures Private Limited & Nippon Life Insurance Company and used by Reliance Nippon Life Insurance Company Limited under license. For more information or any
grievance, 1. Call us between 9am to 6pm, Monday to Saturday on our Toll Free Number 1800 102 1010 or 2. Visit us at www.reliancenipponlife.com or 3. Email us
at:rnlife.customerservice@relianceada.com or 4. Fax: 022 3303 5662.
Beware of Spurious / Fraud Phone calls: IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving
such phone calls are requested to lodge a police complaint.
CIN: U66010MH2001PLC167089
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