(To be executed on Rs. 100 Stamp Paper)
Please choose Channel
*
Retail Sales
Commercial Line
Business Development
FIG
Digital
Call center
Agency type
*
Internal agency
External agency
Name of Internal agent on behalf of TPL Insurance
*
Email of Internal agent on behalf of TPL Insurance
*
example@example.com
This Insurance Agency Agreement (the "Agreement") is made on this date
*
/
Day
/
Month
Year
Agent Details
DETAILS REQUIRED UNDER SECTIONS 98 AND 100 OF INSURANCEORDINANCE, 2000 READ WITH RULE 36 OF THE INSURANCE RULES 2017 (Agent Details)
Agent Name
*
Mr.
Ms.
Mrs.
Prefix
Name
S/O, W/O, D/O Name
*
S/O
D/O
W/O
Name
*
CNIC
*
Expiry Date of CNIC
*
/
Day
/
Month
Year
Agent Email Address
*
Agent Phone Number
*
Format: (0000) 000-0000.
Agent Title/Position
NTN No.
STRN No.
CNIC No.
*
Office PTCL or other number
Fax number (If Any)
Agent Residential address
*
Registered Office Address
*
City
*
Postal Address
*
Please Select
Same as Agent's Residential address
Same as Registered Office Address
Other
Mention Postal Address if selected other
*
Agent Foundation Course
*
Please Select
Yes
Will complete in 6 months
As per SECP requirement agent has to complete this course within 6 months if not dene at the time of agency onboarding
Expiry Date of Agent Foundation Course.
*
/
Day
/
Month
Year
Description of business carried out, other than as an Insurance Agent.
Discloser (if applicable) Any contracts of agency with other insurers.
*
YES
NO
Mention name of insurers
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Back
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DECLARATION
UNDER SECTION 98 & SECTION100 OF THE INSURANCE ORDINANCE, 2000AND RULE 36 OF THE INSURANCERULES 2017.
Name (agent name)
*
First Name
Last Name
CNIC
*
Address (agent address)
*
Date
*
-
Day
-
Month
Year
In case of existing agencies with other insurance companies
Mention insurance companies name
Discloser (if applicable) Confirm if you have any agency with other insurance companies.
*
YES
NO
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Date
-
Day
-
Month
Year
Date
WITNESS DETAILS WITH SIGNATURE
1st Witness Name
*
1st Witness Address
*
Witness 1 Name
*
Witness 1. Address
1st Witness Signature
*
Re-Sign (1st Witness)
*
2nd Witness Name
*
Witness 2 Name
*
2nd Witness Address
*
Witness 2. Address
2nd Witness Signature
*
Re-Sign (2nd Witness)
*
Agent/Applicant Signature
*
Agent Signature 2
*
Agent Signature 3
*
Agent Signature 4
*
Upload required documents
Agent CNIC (Front and Back)
*
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NTN certificate
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STRN certificate
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of
Agent foundation course certificate
*
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of
Last education certificates
*
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Minimum qualification required : Higher secondary school certificate (intermediate) or equivalent
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of
Witness 1 CNIC (Front and Back)
*
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of
Witness 2 CNIC (Front and Back)
*
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of
Other Documents (Signature, Stamp, etc)
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of
I have read and agree
*
I hereby take the sole responsibility for the correctness and trueness of my details provided by me. I undertake that I will not hold the Company responsible in any manner for any transactions effected by the Company due to incorrect details stated by me. I also agreed that I have read all the terms and conditions mentioned in this agreement.
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