PAN No.(User Id) *

Name of the candidate *

Email ID *

Gender* Date of Birth *

Address *

State *

PIN Code *

Mobile *

Telephone *

UIDAI-Aadhaar Card No. *

Verify your personal details given above. It will be required by you for download of your Admit Card, Score Card etc.

Sponsorship Details, if applicable

Name of the Company

Address

State

Pin Code

Contact Person

Phone

Email ID

Professional Qualification

Are you carrying any Reinsurance related activity ?

Are you an Insurance Consultant for a continuous period of 7 years ?

Are you a principal underwriter for last 7 years ?

Have you held the position of a Manager in any one of the nationalized insurance companies in India ?

No of Hours Training undergone :

Training ID *

Training completion date *

Have you appeared earlier for the exam *

No. of Attempts *

Details of Training Institute*

Examination Centre *

Broking Module Opted for *

Applied for *

Do you have insurance background *

Examination Fess : Rs. 2500/- & GST (18%) : Rs. 450/-
Total Fees Charged : Rs. 2950/-

Please Upload Photo *

Your photograph in jpg format, file size below 30 kb. File name should be given as your FullName_PAN Number (e.g.PriyankaDeshmukh_AJCPK1122R.jpg)

Upload Photo :

Copy of Training completion certificate in pdf format below 100 kb. File name should be given as your FullName_PAN Number (e.g. PriyankaDeshmukh_AJCPK1122R.pdf)

Upload Certificate :

I am aware of the Qualification and Eligibility Criteria for Brokers Online Examination as prescribed by IRDAI and declare that I have fulfilled the same. I further declare that the information given by me is true and I am aware that if any deviation from facts is noted or noticed, my application will be considered null and void