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PLI/RPLI Agent Code Application Form

The document is an application form for the allotment of a PLI/RPLI code number, requiring personal details such as name, date of birth, contact information, and educational qualifications. It also includes sections for agent type, experience in life insurance, and recommendations from postal office authorities. The form concludes with a space for the allotment of an agent code number by the DDM(PLI).

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2K views2 pages

PLI/RPLI Agent Code Application Form

The document is an application form for the allotment of a PLI/RPLI code number, requiring personal details such as name, date of birth, contact information, and educational qualifications. It also includes sections for agent type, experience in life insurance, and recommendations from postal office authorities. The form concludes with a space for the allotment of an agent code number by the DDM(PLI).

Uploaded by

bpmpochampalli
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

APPLICATION FOR ALLOTMENT OF PLI/RPLI CODE NUMBER:

1.​ Name of the Applicant​ :

2.​ Date of Birth​ ​ ​ :

3.​ Sex​ ​ ​ ​ :​ ​ Male / Female

4. ​ Father/Husband​ ​ :

5.​ Educational Qualification​ :

6.​ Postal Address​​ ​ :

​ ​ ​ ​ ​

​ ​ ​ ​ ​ ​ City​ ​ ​ ​ State

7.​ Pin-code​ ​ ​ :

8.​ Mobile Number​ ​ :​ +91

9.​ E-mail​​ ​ ​ :

9A) PAN NUMBER :​

9b) Married / Unmarried


10.​ Agent Type​ ​ ​ :​ Deptl Employee (Including GDS) (DE)
​ ​ ​ ​ ​ ​
Designation & Office
​ ​ ​ ​ ​ ​
Retired Employee (FO)​
​ ​ ​ ​ ​ ​
Date of retirement
​ ​ ​ ​ ​ ​
Direct Agent (DA)

11.​ Agent Section​​ ​ :​

12.​ Agent Category​ ​ :

13.​ Agent Exam Status​ ​ :

14.​ License No.​ ​ ​ :


​ (Please enclose photo copy)

​ a) Issue Date​ ​ :

​ b) Expiry Date​​ :

15.​ Details of previous Experience in life insurance business if any :

Date :​ ​ ​ ​ ​ ​ ​ ​ ​ Signature of the Applicant

Place :

Recommendations of the Sr/Supdt of Post Offices

​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Signature
​ ​ ​ ​ ​ ​ ​ ​ ​ Sr/Supdt of Post Offices,
​ ​ ​ ​ ​ ​ ​ ​ ​ ………………………Dn.
Date :​ ​ ​ ​ ​ ​ ​ ​ ​

Place :

----------------------------------------------------------------------------------------------------------------

Agent Code No……………………….allotted on…………………..


​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ DDM(PLI)

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