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) : 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
Rs. Lakhs
Brokerage */Remuneration in any other form* on Renewal Premium First Year Premium Single Premium
2nd Year
3rd Year
2nd Year
3rd Year
a. b c.
2
Grand total
(b)
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
Non-Single Premium Schemes First year Premium Renewal Premium Risk Premium Non-risk Premium
From date
to date
Risk Premium
Non-risk Premium
Nature of payment
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
2nd Year
3rd Year
Others
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
3rd Year
Others
a. b c.
2
Grand total
(b)
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
no. of schemes5
non-risk premium5
amount paid
Risk Premium
Non-Risk Premium
Risk Premium
Non-risk Premium
1 2 3 4 5 6
Grand total
7
Rs. Lakhs All Other Payments *4 Total Payment Nature of payment Accountin Amount g head
Period of arrangement
Type of Business
Premium Income *
a. b c.
2
Grand total
Rs. Lakhs
Accountin g head
Period of arrangement
Amount
2
Grand Total
Page 2 of 15
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
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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
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 *
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.
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
Sl.no.
Code no.1
License no.2
Period of arrangement
Class of business
Premium Income*
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
Sl.no.
Code no.1
License no.2
Nature of payment
From date 1
Accounti ng head
Total Payouts
Amount
a. b c.
Sl.no.
Code no.1
Period of arrangement
Class of business
First premiumof the first policy sold on the basis of the reference of the referral co.*
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
Sl.no.
Code no.1
License no.2
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
Annexure 3
Page 10 of 15
Page 11 of 15
Total Payouts
Page 12 of 15
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
payouts ( i.e. total remuneration from all segments uld be furnished. details pertaining to the concerned person. ce channel is provided.