FORM - IRDA - 5 AF
[See Regulation 7(1)]
APPLICATION FOR RENEWAL OF A LICENCE TO ACT AS SURVEYOR AND LOSS
ASSESSOR (INDIVIDUAL)
Renewal Application is accepted online only on www.irdabap.org.in
Checklist
Please ensure the following:
1) To enclose a copy of the membership certificate issued by the IIISLA (mandatory)
”details are available on www.iiisla.co.in”
2) To submit FORM 12 (annually) online before applying for Renewal to make online
payment of fees (as mentioned in the regulations) through “Net Banking/Demand
Draft/NEFT/RTGS” during application submission.
3) To attach scanned copy of previous license.
4) To attach scanned copies of qualifications duly attested by notary.
5) to attach scanned copy of affidavit duly notarised against S.No. 6 of the application
form.
6) To send Self addressed envelope 4.5” X 10” with Rs.40 postage stamp to IRDA to send
hard copy of the renewed license
7) To submit FORM 12 (annually) online before applying for Renewal.
8) To attach a recent scanned copy of passport size photograph along with the application
form.
Notes: Read with Regulation 7
1. All licensed surveyors shall apply online 30 days before the expiry of the license.
2. Any correction or alteration made in answer to the questions in the application should be
initiated by the applicant.
3. An affidavit of Rs. 10/- duly notarized on non-judicial stamp paper is required to be
scanned and attached for renewal of licenses in the form of a declaration as contained
against S.No. of 6 of the application form.
4. An email notification will be sent to the applicant on successful submission of the
application form.
5. Any change in the information submitted to the authority must be informed to the
authority within 15 days from date of the change for grant of modified license by the
authority.
I request that the below license may be renewed for a further period of five years.
1. Current License Details
SLA No. (mandatory) ……………………….
License Effective Date ……………………….
Date of Expiry
Membership details of Institute:
Membership/ID card No ……………
Date of Issue of ID card ……………
Level of membership allotted ……………
2. Name of Surveyor and Loss Assessor ……………………….
3. Permanent Address ……………………….
4. Present Address ……………………….
(If change in present address, please upload proof doc)
5. Departments allocated
Marine Marine CROP
Dept Fire Engg Motor Misc LOP
cargo Hull INSURANCE
Level of
Membership
6. I declare that since the date of my last application for license
(i) I have not been found to be 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 of an abetment of or attempt to commit any such
Offence by a Court of Competent jurisdiction, and
(iii) I have not been found guilty of or to have knowingly participated in or connived
at any fraud/dishonesty or made any misrepresentation against an insurer or an
insured in the course of any judicial proceeding relating to a policy of insurance
or the winding up of any investigation of the affairs of an insurer, and
(iv) My license has not been cancelled at any time by the Controller of Insurance/
Insurance Regulatory and Development Authority.
(v) I declare that I continue to hold the qualification on the basis of which my licence
mentioned above was issued.
(vi) An undertaking on performance report showing survey work done by me during
the last 5 years of the validity period indicating total number of survey work, and
amount involved in each category of cases, year-wise and company-wise is
attached.
(vii) In addition to surveyor’s work, I am also engaged on other occupations, the
details of which are given below:
Or
I am not engaged in any other occupation.
(viii) I have not been disqualified for any of the provisions neither attracted the
disqualification stated in section 42D of the Insurance Act, 1938.
Occupation status:
Student Professional Business Employee Service Housewife Others
…………
Employment details:
a) Whether applicant is currently employed? Yes/No ……………
b) If yes, provide details below and also attach scanned copy of NOC from employer
Name of Nature of Period of employment
Nature of Organization
Employer Work From Date To Date
(Govt./Semi- (Insurance
govt/Private Firm, survey
insurance company, related,
surveyor firm, PSU, Others)
others)
c) Details of any other business/profession carried out:
Name of Firm Designation Nature of Business
7. Whether the applicant has been in practice as a Surveyor and Loss Assessor on the 31st
May, 1970 ?
If answer is in YES and the applicant does not possess any of the qualifications stated in
Insurance Act, 1938 and rules and regulations made there under the applicant must make
a declaration as given in the Insurance Rules, 1939 and duly sworn before a Magistrate or
a Notary Public.
8. Fee Payment; NET BANKING/DEMAN DRAFT/NEFT/RTGS
A fee of Rs. 100/- + applicable service tax as approved by GOI @ 14% should be paid as
Renewal fee. [Rs.114/-]
In case license is submitted after expiry upto a maximum period of six months, the
license fee will be Rs. 100/- + penalty of Rs. 750/- + applicable service tax as approved
by GOI @ 14% (along with photocopy of qualification duly attested by notary).[Rs.969/-]
9. Declaration
I solemnly declare and confirm that the particulars given above are true to the best of my
knowledge and belief.
Signature of Applicant…………………………
Date:
Place:
