INSURANCE  INSTITUTE OF INDIA,
Universal Building, 6thFloor
Sir Pherozshah Mehta road,
MUMBAI – 400 001
Phones: 022-22872923 and 22874722  Fax: 022- 22873491
APPLICATION FORM FOR INSURANCE SURVEYORS EXAMINATION

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ROLL NO.	                                                          IRDA Enrollment No. & Date

(If you are fresh candidate, please leave 
it blank, else you may write Roll No. allotted to you)
                                                                                                                                                                  
1. Name : _________________________________________________________________

2. Address: 	_______________________________________________________________________

________________________________________________________________________

________________________________________________________________________
3.Qualification:						                         4. Communication:
                  a) Academic / Professional: ___________________________                            a) Telephone: ______________________
                  b) Insurance: _________________________________________                             b) Fax: _____________________________
						                                            c) E-mail:___________________________ 
5.	Date of Birth: __________________  

6.	 Preference of Exam Centre*: (1)_______________________________ (2)_________________________________

7. Subjects Opted for Examination:-  
       A:
Section-I                (Compulsory for all trainees)	

B: Department Opted for Examination:
Departments	FIRE	MARINE CARGO	MARINE HULL	ENGG.	MOTOR	MISC.	L.O.P	
Please Tick 								
•	Fee Structure :  Admission fee  Rs.150/-, Rs.250/- for section- I  and Fee per Paper is Rs. 250/-,  payable by Demand Draft only drawn in favour of  Insurance Institute of India, payable at Mumbai.

8. 	Payment Detail :
Demand Draft Number	Date	Amount (Rs.)	Name of Bank	

9. Practical Training Details:

Name of the Surveyor/Surveyors Firm	Departments allocated to the Surveyor/Surveyors Firm	Category allocated to the Surveyor/Surveyors Firm	Period of Training Undergone (Please mention dates)	Name of persons under whom training is undertaken	

(Signature of Applicant) 									(Signature of Trainer)

10. If you have been already licensed by the Authority, (if yes) please state category:  _______________

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*Examination Centres: - Allahabad, Ahmedabad, Bangalore Chandigarh, Cochin,  Chennai, Cuttack, Delhi, Hyderabad, Jammu, Jaipur, Kolkata, Jalandhar, Lucknow, Mumbai, Patna, Rohtak, Rajkot, Ranchi, Shimla,  Thiruvananthapuram, Udaipur.