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ÑBBØþ·BBVÕB ÏBBVÓBB íBgíºBBÈB For Indian

Candidate
(for Overseas
candidates)
INSURANCE INTITUTE OF INDIA INR INR
PO. Box No. 1507, Mumbai, 400 001. Life Membership Fee 500.00 3500
Website : www.insuranceinstituteofindia.com Registration " 250.00 2500 Per Form
Entry form for Licentiate / Associateship Examination " 300.00 2000 Per Subject
Fellowship and Actuarial Science Examination Late " 200.00 750 Per Form
to be held May / November 200 (For Fresh) Examination Hand Book 50.00 500 Per Copy
(Strike out whichever is not applicable)
SUBMIT THIS ENTRY FORM THROUGH YOUR LOCAL INSTITUTE ONL
ENTRY Y
ONLY
The last date for submitting this new entry form for May and November examination is January 20 and June 20 with normal fees and
January 30 and June 30 respectively with late fees. (Rs: 200/-). If these dates fall on a Sunday or on a holiday the next working day will
be the last day for submitting the form. Instructions for completing the form are given on the reverse. All the particulars should be
written in Block Capital Letters in English only. Candidates should submit their entry form duly filled in only through the local institutes and
not to the Insurance Institute of India directly under any circumstances, (except Overseas Candidates) failing which entry will be rejected.
For Office Use Only
Institute Receipt No. & Date Registration No. Life Membership No.

Entries to be filled in English only (Please use Capital Letters Only)

1. Name (Mr./Mrs./Ms.) __________________________________________________________________________________

(Full Name & Address in BLOCK LETTERS ONLY)

2. Address : __________________________________________________________________________________

__________________________________________________________________________________

City : _____________________________________________________ Pin : ________________________

E-mail : _______________________ Mobile : ___________________ Tel. No.: ________________________

3. Place of Employment : ________________________________________ Date of Birth :

SC STGEN Male Female
Diploma No. Category* Gender (Tick )
*(Please see Employer Code List and Qualification Code List which is given on the Page 19 of the Examination Handbook)
LIFE GEN

4. Employer Code* Qualification Code Branch (Tick )

5. Examination Centre: For centre code, please refer pg. 14 and 15 of Handbook or see overleaf.

1) ______________________________________________ 2) _______________________________________________

6. Quote Subject Numbers in which you would like to be examined. While entering subject number refer to the subject description and
its corresponding number in the Examination Handbook.
Sub. 1 Sub. 2 Sub. 3 Sub. 4 Sub.5 Sub. 6

7. If you were a candidate for our examination in the past, please state your Regn. No. _________________ Institute ___________
Licentiate/Associateship/Fellowship Examination May/November ____________ and Result ___________ Centre __________
a) I declare that I possess necessary qualifications for admission to the above examination as laid down in the current rules and
regulations. I know that the examination fees are not refundable or adjustable in any manner, if I am found not eligible for the
Examination or the Examination is postponed, cancelled or its time-table changed for whatsoever reasons. I also agree to
abide by the terms & conditions mentioned in Examination Hand Book.
b) I am a member of _______________ Insurance Institute, My Membership No. is ________________ and my membership
subscription for 20 _________ has been paid as per receipt no. ________________ of ________________ institute.
c) My Associateship/Fellowship Diploma no. _____________________________ (it should be in-force). Diploma fees paid vide
Receipt No. ___________________ dt. _________________ of ____________________ institute.

Place _______________________ Date __________________ Candidate’

Candidate’ss Signature ________________________

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INSTRUCTIONS FOR COMPLETING THE FORM

I. Description of Subjects and their corresponding numbers for Licentiate Examination as well as a
list of centers at which the examinations are generally held are given in Handbook. Refer to them
while completing the entries in item Nos. 4 & 5 on the reverse.

II. Payment only by Cash / Money Order or Demand Draft in favour of local institute be accepted.
Postal Order and Cheques will not be accepted.

III. Candidates for Fellowship Examination should give their Associateship Diploma numbers inforce
and the receipt number in column 9 (c) on the reverse.

i) INDIAN CENTRES CODE LIST

Centre Code Centre Code Centre Code Centre Code
Agartala - 205 Cuddapah - 161 Jorhat - 189 Rajahmundry - 215
Agra - 101 Cuttack - 153 Jullundur - 128 Rajkot - 144
Ahmedabad - 102 Dehradun - 162 Kanpur - 129 Ratlam - 204
Ajmer - 103 Delhi - 112 Karimnagar - 230 Ratmagiri - 232
Aligarh - 226 Dharwad - 113 Karnal - 188 Salem - 145
Allahabad - 104 Dibrugarh - 168 Kolhapur - 164 Sambalpur - 190
Alwar - 198 Dimapur - 213 Kolkata - 121 Satara - 146
Amravati - 212 Ernakulam (Cochin) - 115 Kota - 210 Satna - 219
Amritsar - 105 Goa - 165 Kottayam - 207 Shahdol - 227
Andaman (Port Blair) - 166 Gorakhpur - 203 Lucknow - 130 Shimla - 201
Asansol - 106 Gulbarga - 197 Ludhiana - 199 Silchar - 175
Aurangabad - 181 Guntur - 117 Machilipatnam - 131 Solapur - 202
Bangalore - 107 Guwahati - 116 Madurai - 133 Srigamgamagar - 182
Bareilly - 170 Gwalior - 118 Mangalore - 200 Srinagar - 147
Baroda - 173 Haldwani - 209 Meerut - 134 Surat - 148
Behrampur - 223 Hazaribaug - 228 Mumbai - 108 Thane - 194
Belgaum - 221 Hissar - 195 Mysore - 136 Thanjavur - 149
Bhagalpur - 220 Hyderabad - 119 Nagercoil - 137 Trichy - 150
Bhavnagar - 211 Imphal - 233 Nagpur - 138 Trinulveli - 149
Bhilai - 196 Indore - 122 Nanded - 225 Trivandrum - 151
Bhopal - 163 Jabalpur - 123 Nashik - 139 Tuticorin - 167
Bikaner - 206 Jaipur - 124 Nellore - 214 Udaipur - 176
Bongaigaon - 224 Jalgaon - 229 Patna - 142 Udupi - 152
Calicut (Kozicode) - 109 Jalpaigun - 125 Pondicherry - 174 Varanasi - 154
Chandigarh - 110 Jammu - 185 Pune - 140 Vellore - 208
Chennai - 132 Jamshedpur - 126 Raichur - 191 Vijaywada - 155
Coimbatore - 111 Jodhpur - 127 Raipur - 143 Visakhapatnam - 156
Warangal - 192

ii) OVERSEAS CENTRES CODE LIST

Centre Code Centre Code Centre Code Centre Code

Abu Dhabi - 187 Colombo - 180 Kampala - 159 Muscat - 183
Alkhobar - 178 Dar-E-alam - 231 Kathmandu - 184 Nairobi - 218
Baharain - 169 Doha - 217 Kuwait - 193 Riyadh - 179
Bangkok - 216 Dubai - 171 Maputo - 177 Suva-Fiji - 158
Bhutan - 160 Jeddah - 172 Mauritius - 186
(For overseas condidate $1 = INR 50)