SPONSORSHIP FORM

DO Name : _________________
Mobile No. : _________________
DO Code : _________________
Branch Code : _________________
Sponsorer Company Name : LIFE INSURANCE CORPORATION OF INDIA
In Charge/Authorized Person Name : __________________________________________
License Type : Individual Corporate
Insurance Category : Life / General (All fields marked in * are manatory)
Is Specified Person? : Yes / No If Yes, License No. : _____________

Application Details : Applicant Photo

Application Date (dd/mm/yyyy)* : ____________________________
Personal Information
Applicant Name Mr./Mrs./Ms/Dr. : ____________________________
Father / Husband Name : ____________________________
Category : General / SC / ST / OBC
Area : Urban / Rural
PAN : ____________________________
Driving License No. : ____________________________
Passport No. : ____________________________
Voter Identity Card : ____________________________
Photo ID Card of Govt. : ____________________________

Basic Qualification Details* : Class X / Class XII

Board Name *: ___________________________ Roll Number *: ______________________
Year of Passing *: _________________________ Educational Qualification *: Any of Below:
[ ] Class X [ ] Class XII [ ] Graduate [ ] Post Graduate [ ] Associate/Fellow of actuarial Society of India
[ ] Associate/Fellow of Insurance Institute of India [ ] Associate/Fellow of Institute of Chartered Accountants of India
[ ] Associate/Fellow of Institute of Costs and works A/cs. of India [ ] Master of Business Administration
[ ] Associate/Fellow of Institute of Company Secretaries of India [ ] others:_________________________
Date of Birth (dd/mm/yyyy)* :________________________ Sex : Male/Female
Primary Profession :________________________ Nationality : Indian
Contact Information
Current Address Permanent Address
House Number * _________________________________ House Number * ______________________________________
Street / Road * __________________________________ Street / Road * _______________________________________
Town / City * ___________________________________ Town / City * _________________________________________
State * ________________________________________ State * ______________________________________________
District * ______________________________________ District * ____________________________________________
Pin Code * _____________________________________ Pin Code * __________________________________________
Phone No. * ___________________________________ Phone No. * ___________________________________
Mobile No. * ___________________________________ Mobile No. * ___________________________________
E-mail ID * _____________________________________ E-mail - must for online training
Other Information Insurer Ref. No. * _____________________________________
Note : If any of the relative of applicant is in Govt./semi Govt. services. Date on which reference made to DO & other
details if any
If applicant related to any other agent / DO / ME / member of staff. Date on which reference made to DO & other
details if any
Applicant Training Details : Applicant Examination Details :
Training Mode : Online / Offline Examination Mode * : Online / Offline
ATI location : ________________________________ Examination Body * : ________________________________
Training Institute Name * : _____________________ Examination Center * : _______________________________
Accreditation No. * : _________________________ Examination language * : _____________________________

MR No. ____________ Date : _____________________ All documents verified from original

For Rs. 150 Branch Incharge
Name :
Designation :
Division Name : _______________________________
Branch Name : _______________________________
Name of the Candidate : _______________________________
(In case of renewal, Name of the agent)
Unique reference number : _______________________________
(For new cases) (URN)
Agency Code : _______________________________
License No. : _______________________________

Photograph :
(Passport Size)

Signature :