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Nomination Form
Agent Nomination Form
Registration Form
Nomination Form
Agent Nomination Form
Registration Form
Award Category List
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Entry Nomination Form
Name
*
:
Mr
Miss
Mrs
Name of the Company (If Any) :
GST Number
*
:
State
*
:
select
City
*
:
select
Pincode
*
:
Mobile Number
*
:
Alternate Mobile Number :
Email ID
*
:
Date of Birth
*
:
(dd/mm/yyyy)
Your Gender
*
:
Male
Female
You are applying under
*
:
Agent
POS
IMF
Corporate Agent
Applying Under
*
:
Select Category
Life Insurance
General Insurance
Health Insurance
Name of Insurance companies you have agency with? :
Name of the broker you have agency with? :
Fresh Premium Collection from 1.4.2019 to 31.3.2020 ( Excluding GST ) :
*
:
Number of clients
*
:
IRDAI registration No
*
:
Referred by :
Designation
*
:
Office Landline No :
Office Landline extension no :
Residence Landline :
Address :
Number of Nomination/s
*
:
Amount Payable
*
:
{{Nominee.Amount}}
Method of Payment
*
:
Select Pay Method
Please raise invoice to make payment
We will pay by NEFT within 2/3 days
We will pay by Cheque within 2/3 days
Why do you think you deserve this award ?
*
(Please enclose document/s in PDF Format)
Upload Document
Brief About Your Company
Your Photo
*
:
Upload Picture
Please upload your Visiting Card
*
:
Upload Card
IMPORTANT
1. One form can be used for one category only.
2. Multiple nomination is allowed.
If any information found wrong the nomination will be cancelled.
Submit
Entry Nomination Form
Nomination Type
*
:
Agent
Broker
Company
Category
*
:
Company Name
*
:
GST Number
*
:
Pincode
*
:
Address :
City
*
:
Details of the person filling this form
Name
*
:
Profession/ Designation :
Email Id
*
:
Mobile No.
*
:
Office Landline :
Office Ext. :
DOB :
(dd/mm/yyyy)
Gender
*
:
Male
Female
Residence Landline :
Visiting Card
*
:
Upload Card
Number of Nomination/s
*
:
Amount Payable
*
:
{{Nominee.Amount}}
Method of Payment
*
:
Please raise invoice to make payment
We will pay by NEFT within 2/3 days
We will pay by Cheque within 2/3 days
Why you think your Company deserve this award ?
*
Brief About Your Company
Attach Document
(Please enclose documents in PDF Format)
:
Upload Document
Company Logo
*
:
Upload Picture
Submit
Our Details
Our GST NO
27AANFB3885F1Z5
SAC NO
998596
PAN CARD NO
AANFB3885F
IFSC CODE
DCBL0000031
BANK ACCOUNT NUMBER
03121900006071
BANK
DCB BANK LIMITED.
NAME OF THE COMPANY
BUSINESS IDEAS
For more details call us on +91 7977733908
Delegate Registration Form
Register As
*
:
Agent
Broker
Company
Name
*
:
Mr
Miss
Mrs
Name of the Company
*
:
Your Company is
*
:
Select Category
Life Insurance Company
General Insurance Company
Health Insurance Company
Agriculture Insurance Company
Re-Insurance Company
TPA
Web Aggregator
Agents
POS
Education
Composite Broker
Direct Broker- General
Re-insurance Broker
Direct Broker - Life
Direct Broker - General & Life
Corporate Agent
Insurance Marketing Firm
Other
GST Number
*
:
Pincode
*
:
Designation
*
:
Email ID
*
:
Mobile Number
*
:
Date of Birth :
(dd/mm/yyyy)
Your Gender
*
:
Male
Female
Office Landline No :
Office Landline extension no :
Residence Landline :
City
*
:
Address :
Number of Nomination/s
*
:
Amount Payable
*
:
{{Nominee.Amount}}
Method of Payment
*
:
Please raise invoice to make payment
We will pay by NEFT within 2/3 days
We will pay by Cheque within 2/3 days
Why do you think you deserve this award ?
*
(Please enclose document/s in PDF Format)
Upload Document
Brief About Your Company
Your Photo
*
:
Upload Picture
Please upload your Visiting Card
*
:
Upload Card
Submit
For more details call us on +91 7977733908
TIAVA_Online Nomination Form
Name
*
:
Mr
Miss
Mrs
Address
*
:
Pincode
*
:
Mobile Number
*
:
Email ID
*
:
IRDAI Registration Number
Name of Insurance companies you have agency with :
India’s Best Insurance Company voted by Insurance agents?
*
Life
Select
General
Select
Health
Select
India’s Best Insurance Company in claim settlement voted by Insurance agents?
*
Life
Select
General
Select
Health
Select
India’s Best Insurance Company in customer service voted by Insurance agents?
*
Life
Select
General
Select
Health
Select
India’s Most Popular Insurance Company voted by Insurance agents?
*
Life
Select
General
Select
Health
Select
India’s Best Insurance Company for pay-outs & incentives voted by Insurance agents?
*
Life
Select
General
Select
Health
Select
India’s Best Insurance Company in digital convenience voted by Insurance agents?
*
Life
Select
General
Select
Health
Select
Submit
For more details call us on +91 7977733908
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