ANNEXURE ‘A’
Form No. 3058A
LIFE INSURANCE CORPORATION OF INDIA
Name and Address of Agent :
_______________________
_______________________
_______________________
The Sr./Divisional Manager,
Life Insurance Corporation of India.
________________Divisional Office.
Dear Sir,
In consideration of your having granted and agreed to grant me advance from time to time against the
commission that I may be entitled to in respect of the business completed by me for the purpose laid down in
the scheme of Advances to Agents formulated by the Corporation, and as it may be amended by the
Corporation from time to time*/ I hereby agree to pay the interest on each of the advances from the date
thereof at the rate which is in force time to time under the scheme and I hereby irrevocably direct, authorize
and empower you to recover the amounts of all such advances and interest as may be outstanding from time
to time in full from the commission accruing due come from time to time.
I hereby agree, that in case I fail to submit within two months from the ate of grant of any advance, the
receipts, vouchers, etc. that may be relevant in respect of each advance in proof of having utilized the
advance for the purpose for which it was granted, the outstanding advance shall be recoverable from me in 12
monthly installments together with interest at 12% per annum payable half yearly/* or at such enhanced rate /
as may be in force at the relevant time under the scheme.
*And I hereby agree that if in any year I do not qualify for continuance of membership of Chairman’s/ZM’s/BM’
Club of agents and become a member of a lower grade of club or become ineligible to become a member of a
lower grand of club or become ineligible to become a member of any of the above clubs of agents, I shall from
the date of such change pay interest @ 12% per annum payable half yearly or such other rate of interest as
may be decided upon by the Corporation from time to time for advance under the scheme, on the amount of
advance then outstanding against me which is in excess of the amount of advance if any to which I might be
entitled to under the scheme as a member of a lower grade club or as an agent ineligible to be a member of
any such club.
And I hereby, agree and undertake to make all such applications as may become necessary from time to time
to renew my licence to work as an Insurance Agent and to obtain the requisites licence from time to time as
may be necessary to enable me to receive and take such commission and not to do ay act or thing, whereby
any such licence may be revoked or whereby I may be prevented by law in ay way from receiving and
recovering such commission in future.
And I hereby further, agree that on termination of my agency either by death or any cause whatsoever ay
outstanding balance of the advance made by the Corporation with interest thereon will be a first charge on
any moneys payable by the Corporation to me or to my heirs, assignees or nominees in respect of renewal
commission or any account whatsoever.
Dated at __________________ this _________day of ______ 20____
Yours faithfully,
Signature _____________________
Name ________________________
Ag.Code No. __________________
Signature attested by :
Designation :
Office Seal :
