ORGANISATION - STRUCTURE Status of the Applicant: (e.g. Limited company-Private/Public, LLP/ Cooperative Society. If listed, names of Stock Exchanges and latest share price to be given) Category of Applicant Details of Registration Date of Incorporation DD_MM_YYYY Place of Incorporation Name of stock exchanges (In case of listed Company) Cooperative Society JRB.RSR.RGN 02_02_1973 DAVANGERE KARNATAKA NA List of major shareholders (holding 5% and above of applicant directly or along with associates) (The information is required to be furnished by the applicant falling under category 4(1)(ii) of the regulations) Share holding as on: Name of shareholder No of Shares held % of total paid up capital of the company NIL NIL Particulars of all Directors/Partners NAME DESIGNATION QUALIFICATION SHARE IN CAPITAL IN OTHER COMPANIES Sri N.M.J.B. Aradhya President PUC NIL NIL Sri Ramanlal .P. Sanghavi Vice President PUC NIL NIL Sri Kirvadi .V. Somashekhar Director PUC NIL NIL Sri Krishnasa Bhute Director BA NIL NIL Sri A. H. Kuberappa Director BE NIL NIL Smt Jayamma Parashuramappa Director 10TH NIL NIL Sri S. K. Veeranna Director DIPLOMA IN AUTOMOBILE NIL NIL Sri H.N. Basavaraj Director BE NIL NIL Sri Shankar Katawkar Director B Com NIL NIL Sri Suresh Gowdar Director BA NIL NIL Sri N.A. Murugesh Director BE NIL NIL Sri S.K. Prabhuprasad Director PUC NIL NIL Smt Shashikala Rudraiah P M Director PUC NIL NIL Sri B.G. Wodeyar Professional Director CA NIL NIL Sri B.S. Hiremath Professional Director BA NIL NIL
Professional Qualification Name of the Institute Country Qualification Year of Study INSURANCE INSTITUTE OF INDIA MUMBAI INDIA AIII 04.04.1997 Working Experience Name of the Employer Nature of Business Designation Description of Duties Period LIC INSURANCE MANAGER ADMIN/MARKETING 37 YRS List Of Specified Persons who will be responsible for Soliciting And Procuring Insurance Business Name Address PAN/ ADHA R No. Qualification (Including Insurance ment Details of Respon sibilities Exam pass Certificate issued by Examination Body as per Regulations SHANMUKAPPA GOWDA HV #79/2,SILVER JUBILEE BUILDING,P B AWZPS8922Q M Com NA ALL BANK ACTIVITIES C000045810 DECLARATION (This declaration is to be signed by two of the directors, two of the partners as the case may be) I/We hereby apply for registration. I/We have gone through the Insurance Regulatory and Development Authority of India (Registration of Corporate Agents) Regulations, 2015 and am/are satisfied that I/We am/are eligible to apply for the corporate agency registration. I/We state that I/We have truthfully and fully answered the questions above and provided all the information which might reasonably be considered relevant for the purposes of my/our registration. I/We declare that the information supplied in the application form is complete and correct. I/We undertake that I/We shall not allow or offer to allow, either directly or indirectly, as an inducement to any person, any rebate of the whole or part of the remuneration earned by me/us during the registration period. I/We undertake to service the run-off business on the books at the time of cancellation or non- renewal of registration. I/We declare that I/we do not possess an insurance agent license or insurance broker registration or any other license/registration issued by the Authority. For and on behalf of