Registration

	LIFE INSURANCE ROUND TABLE
	211, Nav Neelam C.H.S. R.G. Thadani Marg, Above Sadanand Hotel Worli, Mumbai-400 018
	Tel:(91-22) 24913369/66623966 TeleFax:66669228 E-MAIL:lirt@hathway.com WEBSITE: www.lifeinsuranceroundtable.org

24^th ANNUAL CONVENTION (Residential)

Please stick
the
photograph
of attending
participant

SEPTEMBER 18-20, 2011, PRE-CONVENTION 17^th September, 2011
THEME: Perform To Win
VENUE: The Oberoi Grand Hotel - Kolkata

NAME:*
ADDRESS:
STATE:
PIN:
STD CD:
(R):
(O):
FAX:
MOBILE:
PAGER:
E-MAIL ID:
2010 LIRT REGISTRATION:
Choice of Room Partner:
Headphone (Hindi Translation):	YES NO
Note : Please Staple Passport Size Photographs

DATE OF BIRTH:

(dd/mm/yyyy)

QUALIFICATION:

COMPANY NAME:

DESIGNATION:

DATE OF APPOINTMENT:

(dd/mm/yyyy)

AGENCY CODE NO.:

BRANCH:

DIVISION:

CLUB Membership:

MDRT:		TIMES QUALIFIED	ATTENDED:
LIRT:		TIMES QUALIFIED	ATTENDED:

FIRST TIME ATTENDEE :

YES NO

FOOD :

VEG NONVEG JAIN

QUALIFYING CONDITIONS:

1. Rs. 5, 00, 000/- First Year Commission with Bonus from 1.4.2010 to 31.3.2011
40% Credit for Personal Accident and Mediclaim commission only for above.
2. 65% of all the above conditions for the Rural Area agents and agents aged 65 years and above.
Certifying Letter from Branch Manager of F.Y. commission with bonus from 01.04.2010 to 31.03.2011

Star Agent:	Rs. 12,00,000/- (F. Y. Commission with Bonus)	}	Special felicitation.
Twinkle Star:	Rs. 24,00,000/- (F. Y. Commission with Bonus)
Managers Session:	(Exclusive) 17^th September. 2011.

Dues:	Participation Fees: (Includes Registration, Stay & All Meals) (Non-refundable)	On or Before
	Rs. 14,000/-	10.10.2010
	Rs. 17,000/-	31.12.2010
	Rs. 20,000/-	10.04.2011
	Rs. 25,000/-	There after
Refund Policy: No refund after 15^th July, 2011. No carry forward after 10^th August 2011.

I hereby certify that I will adhere to the code of ethics of Life Insurance Round Table
Sign :_______________________	Paid : Rs._________________	Cash / DD No.____________
Dated_______________________	PAYABLE BY BANK:______________________________________
Cheque for the participation fees is to be written in favour of "LIFE INSURANCE ROUND TABLE".

For Office Use :

Approved / Declined

President / Vice-President /Secretary

Signature:_________________________________________

Rights reserved for the approval & membership solely with LIRT Committee.