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Format for Life Insurance Companies Name of the Insurance Company (with Registration No.

) : Financial Year : Statement of particulars of Commission / any other remuneration as per section 31B(2) of Insurance Act, 1938. I)Payment to Individuals (i)Payment to Individual Agents
Break up of the Premium Income generated through the tieup/arrangement Period of arrangement Sl.no 1 2 Name of the Code no. License no. . person Class of business First Year From date to date Assurance Annuity Total Single Premium 2nd Year Premium Income* Renewal 3rd Year Others Total Premium Income Details of the Remuneration
3

Annexure 2

Rs. Lakhs

Commission*/Remuneration in any other form* on Renewal Premium First Year Premium Single Premium 2nd Year 3rd Year Others

All Other Payments *4 Total remunerati on Nature of Accounti payment ng head Total Payment Amount

a. b c.

2
Grand total

(ii)Payment to Brokers (a) under Individual policies


Break up of the Premium Income generated through the tieup/arrangement Period of arrangement Sl.no Name of the Code no.1 License no.2 . person Class of business First Year From date to date Assurance Annuity Total Premium Income* Renewal Single Premium Total Premium Income Others Details of the Remuneration
3

Rs. Lakhs

Brokerage */Remuneration in any other form* on Renewal Premium First Year Premium Single Premium

All Other Payments *4 Total Payment Amount

2nd Year

3rd Year

2nd Year

3rd Year

Total Remunerati Nature of Accounti on Others payment ng head

a. b c.

2
Grand total

(b)

under Group/Pension Schemes


Premium Income* Period of arrangement

Remuneration on the premium income*3 On Single Premium Schemes Payments made at new business procurement stage Brokerge no. of paid schemes5 non-risk premium5 amount paid on Non-Single Premium Schemes Payments made at new business Remuneration on Renewal procurement stage Brokerge premium paid on non-risk amount no. of risk amount First year no. of premium schemes premium5 paid schemes6 premium6 paid
5

Rs. Lakhs All Other Payments *


4

Sl.no 1 2 Name of the Code no. License no. . person

Single Premium Schemes

Non-Single Premium Schemes First year Premium Renewal Premium Risk Premium Non-risk Premium

From date

to date

Non-Risk Risk Premium Premium

Risk Premium

Non-risk Premium

Nature of payment

Account Amoun ing t head

Total Payment

1 2 3 4 5 6
Grand total

II)Payment to 'Other than Individuals' (excluding bancassurance channel) (i) Payment to Corporate Agents
Break up of the Premium Income generated through the tieup/arrangement Sl.no Name of the Code no.1 License no.2 . person Whether Related party (Y/N) Period of arrangement Class of business First Year From date to date Premium Income* Renewal Single Premium Total Premium Income Others Details of the Remuneration
3

Rs. Lakhs
4

Commission* / Remuneration in any other form * on Renewal Premium First Year Premium Single Premium

All Other Payments * Total Remuner Nature of Accountin ation payment g head

Total Payment Amount

2nd Year

3rd Year

2nd Year 3rd Year

Others

Assurance Annuity Total

a. b c.

2
Grand total

Page 1 of 15

Format for Life Insurance Companies (ii)Payment to Brokers (a) under Individual policies
Break up of the Premium Income generated through the tieup/arrangement Whether Related party (Y/N) Period of arrangement Class of business First Year From date to date Single Premium 2nd Year Premium Income* Renewal Total Premium Income Others Details of the Remuneration
3

Rs. Lakhs

Brokerage */Remuneration in any other form* on Renewal Premium First Year Premium Single Premium

All Other Payments * Total Remuner ation Nature of Accountin payment g head

Sl.no Name of the Code no.1 License no.2 . person

Total Payment Amount

3rd Year

2nd Year 3rd Year

Others

Assurance Annuity Total

a. b c.

2
Grand total

(b)

under Group and Pension Schemes


Premium Income* Period of arrangement

Remuneration on the premium income*3 On Single Premium Schemes Payments made at new business procurement stage Brokerge paid on Non-Single Premium Schemes Payments made at new business Remuneration on Renewal procurement stage Brokerg premium e paid on First non-risk amount no. of risk amount year no. of 5 premium5 paid schemes6 premium6 paid premiu schemes m

Rs. Lakhs
All Other Payments *4 Total Payme nt

Single Premium Schemes

Non-single Premium Schemes First year Premium Renewal Premium

Sl.no Name of the Code no.1 License no.2 . person

Whether Related party (Y/N)

no. of schemes5

non-risk premium5

amount paid

From date to date

Risk Premium

Non-Risk Premium

Risk Premium

Non-risk Premium

Risk Non-risk Premium Premium

Nature Accoun of ting Amount paymen head t

1 2 3 4 5 6
Grand total
7

(iii) Payment to TPA's

Rs. Lakhs All Other Payments *4 Total Payment Nature of payment Accountin Amount g head

Sl.no 1 2 Name of the Code no. License no. . TPA

Whether Related Party (Y/N)

Period of arrangement

Type of Business

Premium Income *

Fee/Renum eration paid*

From date to date

Individual Group Total

a. b c.

2
Grand total

(iv) Payment to Referral companies


First premiumof the first Commission policy sold on the basis of paid*/payable in the reference of the respect of the premium referral co.* Class of business First year Premium From date to date 1 Assurance Annuity Total Single Premium 2 On First Year Premium 3 On Single in respect in respect of Premium of 3 4 4 5 6 7

Rs. Lakhs

Referral fee paid * Total Referral fee paid *

Accountin g head

All Other Payments *

Sl.no Code no.1 .

Referral reference no.2

Name of the Whether Referral Related company Party (Y/N)

Period of arrangement

Total Payment in respect of 7 8 Nature Account of ing head payment

Amount

2
Grand Total

Page 2 of 15

Format for Life Insurance Companies III) Payment to Bancassurance channel


Break up of the Premium Income generated through the tieup/arrangement Whether Related party (Y/N) Period of arrangement Premium Income* Class of business First Year From date to date Single Premium 2nd Year Renewal 3rd Year Others Total Premium Income Details of the Remuneration3 Commission*/ Remuneration in any other form * on Renewal Premium First Year Premium Single Premium 2nd Year 3rd Year Others Total Remuner ation All Other Payments *4 Total Payment Nature of Accountin payment g head Amount

Sl.no Name of the Code no.1 License no.2 . Bank

Assurance Annuity Total

a b c

2
Grand total

* as accounted in the books of accounts during the year 1 = Code no. if any alloted by the Insurance co. 2 = issued by IRDA 3 = Remuneration as per Sec 40 A(1) of Insurance Act 1938 / Regulation 19 (1) of IRDA ( Insurance Brokers ) Regulations, 2002 4 = Whether paid/incurred or reimbursed 5 = Based on which payments are made at new business procurement stage 6 = Based on which remuneration on subsequent servicing is made 7 = Including TPA's registered in other jurisdiction

Page 3 of 15

Format for Life Insurance Companies

Page 4 of 15

Format for Life Insurance Companies

Page 5 of 15

Format for General Insurance Companies Name of the Insurance Company (with Registration No.) : Financial Year : Statement of particulars of Commission / any other remuneration paid as per section 31B(2) of Insurance Act, 1938. I) Payments to Individuals (i)Payment to Individual Agents
All other Payments *3 Class of business Premium Income* Commission * Nature of payment Accountin g head Total Payouts Rs. Lakhs

Annexure 3

Sl.no.

Code no.1

License no.2

Period of arrangement Name of the person

Amount

From date to date 1 Fire (General ) IAR ( General ) Engineering (General) Fire ( Large Risks) IAR(Large Risks) Engineering ( Large Risks) Motor (TP) Motor(OD) WC/Employer's Liability Public Liability Act Marine Hull Marine Cargo Health Other business Total Grand total (ii)Payment to Brokers a b c d

Rs. Lakhs

Sl.no.

Code no.

License no.

Period of arrangement Name of the person Class of business Premium Income* Brokerage *

All other Payments *

Total Payouts Nature of payment Accountin g head

Amount

From date to date 1 Fire (General ) IAR ( General ) Engineering (General) Fire ( Large Risks) IAR(Large Risks) Engineering ( Large Risks) Motor (TP) Motor(OD) WC/Employer's Liability Public Liability Act Marine Hull Marine Cargo Health Other business Total a b c d

. 2

Grand total

Page 6 of 15

Format for General Insurance Companies II)Payment to 'Other than Individuals' (excluding bancassurance channel) (i) Payment to Corporate Agents
Whether Related Party (Y/N) Period of arrangement Rs. Lakhs All other Payments *3 Class of business Premium Income* Commission * Nature of payment Accountin g head

Sl.no.

Code no.

License no.

Name of the person

Total Payouts

From date 1

to date Fire (General ) IAR ( General ) Engineering (General) Fire ( Large Risks) IAR(Large Risks) Engineering ( Large Risks) Motor (TP) Motor(OD) WC/Employer's Liability Public Liability Act Marine Hull Marine Cargo Health Other business Total Grand total

Amount

a b c d

(ii)Payments to Brokers

Rs. Lakhs All other Payments *3

Sl.no.

Code no.1

License no.2

Name of the person

Whether Related Party (Y/N)

Period of arrangement

Class of business

Premium Income*

Brokerage * Nature of payment Accountin g head

Total Payouts

Amount

From date 1

to date IAR ( General ) Engineering (General) Fire ( Large Risks) IAR(Large Risks) Engineering ( Large Risks) Motor (TP) Motor(OD) WC/Employer's Liability Public Liability Act Marine Hull Marine Cargo Health Other business Total Grand total a b c d

Page 7 of 15

Format for General Insurance Companies


Rs. Lakhs

(iii) Payment to TPA's 4


Whether Related Party (Y/N) Period of arrangement Type of Business Premium Income * All Other Payments * Fee/Renumeration paid*
3

Sl.no.

Code no.1

License no.2

Name of the TPA

Nature of payment

From date 1

to date Individual Group Total

Accounti ng head

Total Payouts

Amount

a. b c.

2 Grand total (iv) Payment to Referral companies


Rs. Lakhs

Sl.no.

Code no.1

Referral reference no.2

Name of the Referral company

Whether Related Party (Y/N)

Period of arrangement

Class of business

First premiumof the first policy sold on the basis of the reference of the referral co.*

Commission paid* /payable

Referral Accountin fee paid * g head in in respect respect of 3 of 2

All Other Payments *3

From date 1

to date IAR ( General ) Engineering (General) Fire ( Large Risks) IAR(Large Risks) Engineering ( Large Risks) Motor (TP) Motor(OD) WC/Employer's Liability Public Liability Act Marine Hull Marine Cargo Health Other business Total Grand Total

Nature of payment

Accounti ng head

Amount

a b c

Page 8 of 15

Format for General Insurance Companies III) Payment to Bancassurance channel


Whether Related Party (Y/N) Period of arrangement Rs. Lakhs All other Payments * Class of business Premium Income* Commission * Nature of payment Accountin g head
3

Sl.no.

Code no.1

License no.2

Name of the Bank

Total Payouts

From date 1

to date IAR ( General ) Engineering (General) Fire ( Large Risks) IAR(Large Risks) Engineering ( Large Risks) Motor (TP) Motor(OD) WC/Employer's Liability Public Liability Act Marine Hull Marine Cargo Health Other business Total Grand total

Amount

a b c d

2 * as accounted in the books of accounts during the year 1= Code no. if any alloted by the Insurance co. 2 = issued by IRDA 3 = Whether paid/incurred or reimbursed 4 = Including TPA's registered in other jurisdiction

Page 9 of 15

Format for General Insurance Companies

Annexure 3

Page 10 of 15

Format for General Insurance Companies

Page 11 of 15

Format for General Insurance Companies

Total Payouts

Page 12 of 15

Format for General Insurance Companies

Page 13 of 15

Particulars of Commission/any other remuneration paid as per Sec 31B(2) of Insurance Act, 1938

Instructions to fill the Statements: 1. Only the details (in case of other than bancassurance channel) , whereby the total payouts ( i.e. total remuneratio /classes of business and all other payouts put together) are more than Rs. 5 Lakh should be furnished. 2. Code no./License no./Name of the person should be mentioned in each row of the details pertaining to the conce 3. Full/Registered name of the bank should be given while details under Bancassurance channel is provided. 4. To date column shall show the date of termination/end of an arrangement. 5. Under period of arrangement - From date/to date column shall be in DD/MM/YYYY format. 6. When the agreement with Bancassurance partner is live but no business made, details to be shown as "nil". 7. In the cases where premium/commission is generated/paid even after the termination of the period of the arrange the reasons should be mentioned in the notes. 8. In case of any premium/commission mismatches ( for e.g due to commission claw backs or refunds /rectification of earlier years made if any, in the current year ) reconciliation statement should be provided in the notes. 9. Form applicable in case of Life companies is in Annexure 1 and for General Insurance companies is in Annexure

urance Act, 1938

payouts ( i.e. total remuneration from all segments uld be furnished. details pertaining to the concerned person. ce channel is provided.

ails to be shown as "nil". on of the period of the arrangement,

backs or refunds /rectification entries ovided in the notes. ce companies is in Annexure 2.

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