Application Form for CDA

Please fill in all required details in Block Letters. Please

Application No.

G0086413
Y Y Y Y

Affix Photograph here.

as appropriate.

Date of Appointment
D D M M

*All the below fields are mandatory

PERSONAL DETAILS 1. 2. 3. 4. 5. 6. 7. 8. Name of the CDA (Mr/Mrs/M/s)* Represented by (Mr/Mrs/M/s.)* Father's / Husband's Name* Sex* Date of Birth* Educational Qualifications* Insurance Qualifications (If any)* Residential Address*
D

Male
D M

Female
M Y Y Y Y

SSC

HSC

Graduate

Post Graduate (Specify Discipline)

City State 9. Telephone (with STD code)* Mobile Home Office 10. E-mail* 11. PAN No.* 12. Nominee Details:* Name: of Nominee (Mr./Mrs./Ms): Date of Birth: Bank A/c. No. Bank Name:
*Please attach copy of a cancelled cheque. D D M M Y Y Y Y

Pin Code

Service Tax No.*

Relationship with CDA:

Spouse

Son

Daughter

Father

Mother

Others (Specify) Branch:

Applicable if multiple nominees:

Name Age Relationship with CDA Percentage % % % %

13. Family Background: Immediate family members

Name Age Relationship Profession
Private and confidential.

14. Are you related to any employee of Reliance Life Insurance Company Limited? If yes, please provide details
I do hereby declare that the foregoing statements and answers are to the best of my knowledge and belief, true and complete and that shall be the basis of agreement between me and Reliance Life Insurance Company Limited, and that if any of the foregoing answers or statements are untrue or incomplete the said Contract shall stand automatically terminated from the date on which such knowledge comes to the Company. I hereby confirm and undertake to provide any information regarding my individual/firm/organisation profile and past experience/business/ activities or any other related information to Reliance Life Insurance Company Limited whenever required and will co-operate with any staff of Reliance Life Insurance Company Limited or with any authorised agency for any such information verifications. I further hereby confirm that this Channel Development Associate Application Form has been completed by me in my own handwriting.

Signature Signed by Date

Stamp in case of partnership or Company

Place

15.

Bank Account Details*

(All NEFT Banks are accepted) Please attach a copy of a cancelled cheque Name of the Account Holder Bank Account No, Bank Name Bank Branch City IFSC Code :
(Name of the Account Holder should be the same as CDA Applicant's Name)

: : : : :

CDA Signature

For office use only

CDA Code: CDA Name:

Linkage Details:
Mapped to BSM:

TM / ETM / STM

RM / ZM

ISO 9001:2008
CERTI FI E D CO MPANY

Reliance Life Insurance Company Limited (Reg. No. 121)

Registered Office: H Block, 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai, Maharashtra 400 710, India.

Customer Care Number: 1800 300 08181 & 3033 8181 Email: rlife.customerservice@relianceada.com Website: www.reliancelife.com

Mktg/Application Form/Version 1.3/April 2012

Signature

Checklist
Please tick the appropriate box. Individual HUF Proprietor Partnership Company

Proof of identity provided by Applicant. Please () against the document attached.

Valid Passport* Pancard Valid Driving License*

Mandatory Proof for other than Individual

HUF Proprietor Company : : : HUF Addendum Proprietorship Document Partnership Deed Certificate of Incorporation / Registration of Certificate Memorandum & Articles of Association

Partnership :

Proof of address provided by Applicant. Please () against the document attached.

Valid Passport* Bank Passbook / Statement** Voter ID Latest Electricity Bill** Valid Driving License* Telephone Bill (Only Landline)** House Allotment Letter / Leave License / Rent Agreement *Date of validity should not be less than six months. **Not more than 3 months old. Proofs provided in vernacular language have to be translated in English by the TM/ETM/STM and have to be co-signed by them.

Please Note: 1. 2. 3. 4. 5. Upon receipt, we will examine this form and verify if all supporting documents have been attached and all information has been provided. In case of any further requirement we will revert to you. Our acceptance of this form does not guarantee clearance or approval as a Channel Development Associate (CDA) Reliance Life Insurance Company Limited has the right to reject, disqualify or disapprove any applicant without having to assign any reason whatsoever. No Name change request will be entertained. For other than Individual (HUF / Proprietor / Partnership / Companys), address in the form should match with the given address in mandatory proof document.

Name (SM/TM) : _____________________________________________ SAP Code: ______________________

Signature

: _____________________________________________ Contact No.: ______________________

Mktg/Checklist/Version 1.0/January 2012

ISO 9001:2008
CERTI FI ED CO MPANY

Reliance Life Insurance Company Limited (Reg. No. 121)

Registered Office: H Block, 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai, Maharashtra 400 710, India.

Customer Care Number: 1800 300 08181 & 3033 8181 Email: rlife.customerservice@relianceada.com Website: www.reliancelife.com

Ref: CDA 1View\Doc\12-13\01

Date:

Sub: Declaration of Compliance as per Agreement I/We, _________________ having CDA Code ________ hereby declare that I/We have gone through the agreement and will abide to it in letter & spirit. If I/We fail to comply with the same, I/We permit to RLIC to decide the penalties such as, in addition to the Clause 19 of the agreement, termination of services and/or recovery of any damages and/or losses arises due to the non compliances of the agreement and its schedules and/or other applicable standards and/or Companys standards and/or documented procedures and/or process and/or any other prevailing legal enactments and the Rules, Regulations, Circulars, etc thereof. RLIC is empowered to levy Additional penalties, if any, with or without interest, considering all available legal recourses. Signature of the CDA