FORM - IRDA - 12
[See Regulation 19(b)]
FORMAT FOR ANNUAL SUBMISSION OF RETURN TO THE AUTHORITY

1. Name of Surveyor ………………………………..
2. License Details
Current SLA No ……………………………….. Date of Expiry DD-MM-YYYY
Membership details of Institute:
Membership ID card No ---------------
Date of Issue of ID card ---------------
Level of membership allotted ……………
3. Qualifications acquired in the past 1 year (Upload docs for proof)
a) Academic / Professional ………………………………..
b) Insurance ………………………………..
c) Training Attended ……………………………….. (Nature – Duration for all of the above)
4. No. of surveys done in last financial year and the name of insurers: 20 _____ 20 _____
Insurers
Fire
Marine cargo
Marine Hull
Engg
Motor
Misc
CROP INSURANCE
LOP
Total
A
B
C
D
……
5. Quantum of losses assessed in last financial year: 20XX-20XX
Fire
No.
Marine cargo
No.
Marine Hull
No.
Engg
No.
Motor
No.
Misc
No.
CROP
INSURANCE
No.
LOP
No.
> 10 Lacs
> 1 Lac
> 10 Lacs
> 2.5 Lacs
> 50,000
> 1 Lac
> 10 Lacs
1 - 10 Lacs
25,000 - 1 Lac
2.5 - 10 Lacs
50,000 - 2.5 Lacs
10,000 - 50,000
25,000 - 1 Lac
1 - 10 Lacs
0 - 1 Lac
0 - 25,000
0 - 2.5 Lacs
0 - 50,000
0 - 10,000
0 - 25,000
0 - 1 Lac
Total
6. Declaration
I . .................................. solemnly declare and confirm that the particulars given above are true to the best of my knowledge and belief.
Signature of the applicant…………………………………
Date:
Place: