UNITED INDIA INSURANCE COMPANY LIMTED
Registered Office: 24, Whites Road, Chennai - 600 014

Divisional Office :010700
PUBLIC SECTOR, DARE HOUSE EXTN., (IV FLOOR)
NO:17, RAJAJI SALAI , CHENNAI - 600 001

FIDELITY GUARANTEE PROPOSAL FORM
(Authorised Agents of National Savings Oraganisation Selling Small Savings Securities)
1 Full name and address of Applicant
(in Block Letters)

 

  
2 Age of the Applicant  
3 Please state under what Agency Scheme you are an Agent.  
 
  1. the Standardised Agency System or
  2. the Authorised Agents (Bank)Scheme or both
  
4
  1. Annual Commission drawn during last two years
    (if any)
 a)
 
  1. Full particulars of your other income; if none state "none"
 b)
5
  1. Have you any private debts or liabilities except ordinary accounts for the current year?
 a)
 
  1. If so, state the amount
 b)
6 How long have you resided at your present address? If under 12 months, state previous address and period there.

  
7
  1. Are you surety for any person?
 a)
 
  1. If so, state the particulars
 b)
8 Were you ever bankrupt or insolvent or have you ever arranged with your Creditors?  
9
  1. Have you ever made any application for gurantee before?
 a)
 
  1. If so, state the name of Company the date of application and result.
 b)
10 Mention two householders (not relatives) who have known you for some length of time to  whom the Corporation may refer.  (Please state names and full postal address in Block capitals). 1)

 

2)

 

 
11 Please state the amount for which the Policy is required. Rs................... ........................... ..................
(in words) .................. ........................... .........
I hereby declare that the foregoing answers are correct without any reservation whatsoever on my part.
Date: .........................

...................................................

Signature of Employee
I confirm that the above applicant's form for appointment as an agent has been scrutinised by me and found satisfactory and a certificate of Authority will be issued and the number intimated to the Insurer on receipt of the Fidelity Guarantee Policy.
Date: ......................... .......................................................

Signature of Appointing Authority
Office Seal :

 

 Designation: .......................................................
Address:
.......................................................

.......................................................
Premium Payable Rs........................................................ Date: ..............