Name of the candidate *

Date of Birth *

Address *

PIN *

Mobile *

Telephone *

Email ID *

PAN No.(User ID) *

Note: Existing users Please Add PANNO-1 for Re-registration

UIDAI Aadhaar Card No. *

Sponsorship Details *

Name of the Company

Address

State *

PIN *

Contact Person

Phone

Email ID

Are you carrying any Reinsurance related activity ?

Are you a principal underwriter for last 7 years ?

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

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

Eligible for :

Required Hours :

Professional Qualification

Broking Module Opted for *

Payment Amount : Rs.2596.00/- ( Renewal Course Registration : Rs. 2200/- + 18% GST)

Please Upload Photo *

Your photograph in jpeg format, file size below 30 kb. File name should be given as your PAN Number_Name (e.g. AJCPK1122R_PriyankaDeshmukh.jpeg)

Upload Photo :

Upload your Brokers’ Exam Passing certificate and renewal certificate in pdf format,file size below 100KB. File name should be given as your PAN Number_Name_degree (e.g. AJCPK1122R_PriyankaDeshmukh_degree.pdf)

Upload Certificate :

Course Duration : 60 Days. For Any support, have a look at Contact US page
Please verify PAN NO, E-mail ID and Aadhaar Number before submit your registration form.

I am aware of the Qualification and Eligibility Criteria for Brokers Online Training 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