Star Health and Allied Insurance Co.
Ltd Affixself attested
New door no 48, Old no 21/1,ThatikondaVatsala Ramachandran FoundationBuilding, Casa major road, Latest Passport
(Opp Don Bosco School 2nd Gate), Egmore, Chennai – 600008. Desk No: 044- 4063 3523/24
CIN:U66010TN2005PLC056649,IRDAI Regn.No:129.Email:businesscodes@starhealth.in
size photograph
of the Applicant
MIS FORM – AGENT APPOINTMENT
Note: Please fill the form in CAPITAL LETTERS only [ All fields are COMPULSORY]
1. Applicant Name (As per PAN Card)
2. Title Mr. Ms. Mrs. Mx.
3. Father Name/ Spouse Name
4. Gender : Male Female Transgender
5. Date of Birth (DD/MM/YYYY)
6. Full Address
House/Flat
a) Address 1 Street
No.
b) Address 2
c) Address 3
d) City / District
e) State
f) PIN Code
g) Mobile No: +91-
h) E-mail ID:
7. Rural/Urban Rural Urban
X class XII Class Graduate Post Graduate Other
8. Educational Qualifications
Professional Qualification [ If Any ] :
9. PAN No : P
10. Aadhar No [Optional ]
Details of past/ current association, If any,
11. Yes No If yes, details required – Type of association, code, other details
with STAR HEALTH
Details of relatives working/ worked, If any,
If yes, details required – Type of association, Relative Name, code, other
12. with STAR HEALTHas Employee, Agents, Yes No
details
Vendors, Partner, etc.,
Details of relatives working/ worked in Hospitals/ TPA/ Other If yes, details required – Type of association,
13. Yes No
Insurance Companies Relative Name, companyname, other details
14. Are you facing any criminal case/ convicted by any court Yes No If yes, more details required
Have you been engaged in any employment-related disputes, legal
15. Yes No If yes, more details required
actions or faced any disciplinary actions by any insurance company
Details of Insurance Agency Examination Passed Earlier Requesting Sponsorship for IC – 38 Health Insurance Examination [ For
16. 17.
[ For Composite Agent Only ]– Please tick (a or b or c) Direct Agent Only ] – Please fill Preferred Exam Date,Center and Language
Preferred Preferred
Preferred
a)Life b)General c) Health i ) Exam Exam
Exam Date:
Center: Language:
18. Office Code : Office Name : Zone :
Fulfiller
19. Fulfiller Code : Fulfiller Name :
Designation :
Note:Please attach self attested copies of the following documents which are COMPULSORY.
Form IA ( For Direct Agent ) or Form IB ( For Composite
i ii Copy of PAN Card
Agent)- duly filled and signed by the applicant
iii Copy of Educational Certificates iv Copy of Address Proof
v NEFT Form vi Cancelled Cheque Leaf / Bank Pass Book
Signature of Branch Head
NEFT Details
Name of the Bank Bank Branch
Bank Account No IFSC Code
Declaration:
By signing this form, I acknowledge that all the information provided by me is true and accurate to the best of my knowledge. I understand that any false
statements or omissions may result in disciplinary action, up to and including termination of contract. I authorize the company to verify the information
provided and conduct necessary background checks, including but not limited to agent history, educational qualifications, and references. I also consent
to the company retaining and processing my personal data in accordance with applicable privacy laws for the purposes of appointment-related matters.
The company reserves the right to pull relevant details from the CKYC (Central Know Your Customer) portal, CIBIL or for any other verification
purposes using the PAN, Aadhaar or any other details/ documents submitted by me.
Place : Date: Signature of the Applicant
For Office Use Only [ For BM Incentive Purpose ]
UnitHead Code UnitHead Name UnitHead Designation
20. 21. 22.
