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Form l- C Certificate to be issued bv the lnsurer to Agents on cessation of lnsurance Appointment
We hereby declare that Shri/Smt Shuvankar Sarkar Unique Agency Number 60282563 was appointed
as an lnsurance Agent in our organization: Kotak Mahindra Old Mutual Life lnsurance Ltd. and the
details of the Agency held with us are as follows:
Life lnsu ra nce
Particulars of the Agent
Agents Name Shuvankar Sarkar
Agency Code Number (Allotted by the lnsurer) 60282s63
Date of issue of appointment 25.02.2015
Category of appointment (Life/Non-Life/ Health
Composite) ln case composite furnish nanres of
other lnsurers
Life
PAN NUMBER of the Agent EJQPS7982Q
Date of submitting resignation / surrender of issue
of appointment if any
1.8.12.201,5
Date of acceptance of resignation/ surrender of
issuance appointment if any
1.8.1.2.2015
Reasons for leaving the organization As request by Agent
Remarks of lnsurer if any Nil
sd/-
Designated Official Name
Mr. Prerak Parmar
(lD): i-ife,&rii+ ln S*1774:*
Designation : Vice President
Department: Sales
Date27 .01,.201,6
Place: Mumbai
Kotak Mahindra Old Mutual Life lnsurance Limited
A JOilT yELrUBE UrrTH @ OLD MUTUAL
CIN: U66030MH2000PLC128503, tRDAtRegn.No.: 107, Kotak lnfiniri, Tth Floor, Zone- , Bldg. No.21, lnfinity Park,
Corporate & Registered Office: Opp. Western Express Highway, Gen.A K Vaidya Marg,
4th Floori Vinay Bhavya Complex, 159 A, CST Road, Malad (E), Mumbai - 400 097. lndia.
Kalina,Santacruz(E),Mumbai -400098, lndia. http://insurance.kotak.com Toll free:18002098800
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