Page 208 - Ebook IC S01

86 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III—SEC. 4]

2. This license authorizes the license holder to act as a Surveyor and Loss Assessor for any registered insurer and
therefore, no identifying mark or note of any description by which the identity of an insurer might be
established should be placed on the license.
3. No correction in this license shall be valid unless initialled by the Designated Person of the Authority.

FORM - IRDAI–11
[See Regulation 16(13)]
FORMAT FOR KEEPING RECORDS FOR 3 YEARS
1. Name of Surveyor ………………………………..
2. License Details
Current SLA No ………………………………..
Date of Expiry DD-MM-YYYY

S.No. Name and address of the Insured Name & Address of the Insurer Policy No. Dept in which the claim falls Dt of allocation of survey work Dt of survey/ inspection Dt of submission of survey report Amount of Claim assessed Survey Fee Details (Amnt/ dt. of payment)

Note: The survey reports, photographs, etc. as mentioned in regulations 16(13) shall be kept separately.

FORM - IRDAI-12
[See Regulation 20(2)]
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
3. Qualifications acquired in the past 1 year (Upload docs for proof)
(1) Academic / Professional………………………………..
(2) Insurance ………………………………..
(3) Training Attended ………………………………..
(Nature – Duration for all of the above)

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