FORM - IRDA - 9
[See Regulation 10(1)]
APPLICATION FOR DUPLICATE LICENSE
I regret to inform you that my/ our licence no. …………………………….. expiry date DD-MM-YYYY has been
Lost Destroyed Mutilated
by the following circumstances……………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………………
The fees of Rs. 5/- is also paid below for issue of duplicate license.(Fee Payment: Net Banking/Demand Draft/NEFT/RTGS)
I/ We , therefore request the Authority to kindly issue a duplicate licence in light of the circumstances explained above.
Declaration
I/We, ……………………………. solemnly declare and confirm that the particulars given above are true to the best of my knowledge and belief. Incase the original license is traced, I/We assure you that the same shall be returned to the authority.
………………………………………
Signature of the Applicant
Date:
Place: