FORM - IRDA - 5 AF
[See Regulation 7(1)]
APPLICATION FOR RENEWAL OF A LICENCE TO ACT AS SURVEYOR AND LOSS ASSESSOR (INDIVIDUAL)

Checklist
Please ensure the following:
1) To enclose a copy of the membership certificate issued by the Institute
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
Dept
Fire
Marine cargo
Marine Hull
Engg
Motor
Misc
CROP INSURANCE
LOP
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 Employer
Nature of Organization
Nature of Work
Period of employment
From Date
To Date
(Govt./Semi-govt/Private Firm, insurance company, surveyor firm, PSU, others)
(Insurance survey related, 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/DEMAND DRAFT/NEFT/RTGS
A fee of Rs. 200 should be paid as Renewal fee. In case license is submitted after expiry upto a maximum period of six months, the license fee will be Rs. 200 with a penalty of Rs. 750 (along with photocopy of qualification duly attested by notary).
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: