Agency - PTE Onboarding Form / AD-3.5

1

Application Form

AD v3.5

PLEASE COMPLETE THE FORM IN BLOCK LETTERS IN YOUR OWN HANDWRITING

First Name :

Middle Name :

Last Name :

Place of Birth :

Date of Birth :

Gender :

Father's Name :

Email ID :

Marital Status :

Anniv Date :

Nationality :

PAN Number :

UAN Number :

Aadhaar Number :

Aadhaar Enrolment No :

Blood Group :

Permanent Address :

Pin :

City :

State :

Period of stay (yrs) :

Contact Number (Residence) :

Contact Number (Mobile) :

Current Address :

Pin :

City :

State :

Period of stay (yrs) :

Contact Number (Residence) :

Contact Number (Mobile) :

Education Qualification Details

Qualification	Name of the School / College	Board / University	Period From (MM/YY)	Period To (MM/YY)	Marks Obtained / Out of	Type (Full time / Part Time / Corres)
Post Graduation
Graduation
HSC / 12th
SSC / 10th

2

Work Experience Details

	Employer 1	Employer 2
Organization Name
Address (Main Office / Branch with Board No.)
Employment Type (Permanent/Contract)
Details of Agency (If Deputed)
Employee Code / Number
Start Date (DD/MM/YY)
End Date (DD/MM/YY)
Designation Held
Role & Responsibilities
Reporting Manager Name
Reporting Manager Designation
Reporting Manager Contact Number
Contact No. of HR Manager
Reason for Exit

Do you have any police report/legal cases pending against you?

Yes / No

If yes, kindly furnish details:

Have you defaulted/ delayed on any Loan payments?

Yes / No

If yes, kindly furnish details:

Do you have any loan of value which is more than 6 months of your present CTC?

Yes / No

If yes, please provide purpose of loan:

Have you ever been discharged, dismissed or terminated from any of your employment?

Yes / No

If yes, kindly furnish details:

Are you suffering from any handicaps, ailments or are undergoing long term medication?

Yes / No

If yes, kindly furnish details:

Have you previously been employed with Edelweiss Group in any position?

Yes / No

If yes, kindly furnish details:

Have you previously been interviewed by us for a position?

Yes / No

If yes, kindly furnish details:

Do you have any relatives working for Edelweiss?

Name :

Relationship :

Name :

Relationship :

3

Dependent Family Details (first name will be tagged as Emergency contact)

Name	Relationship	Date of Birth	Address (if different from your address)	Contact Number

Professional References

Name	Current Organization	Current Role	Your Professional Relationship	Contact Number

I undertake that the information provided by me above are true, complete and correct. I agree and understand that, in the event that company finds at any time, that any information provided by me are false or, misrepresented; the company retains the right to immediately withdraw my offer of job or terminate my job, without notice or compensation.

Place :

Date :

Signature :

4

Authorization Letter

To whomsoever it may concern

I hereby authorize Edelweiss Life Insurance Company Limited to verify the documents from an outside Background Screening Agency post my joining the organization, which includes my current/previous Employment history, Educational/Professional Credentials and my Criminal/Address background check.

The outside Background Screening Agency may obtain appropriate information from different sources as per the details mentioned in my application form submitted to my Employer, which includes Employment history from my current/previous employer, Educational / Professional Credentials to be checked from School / College / University / Autonomous Institute and my Criminal / Address background check from Civil/Credit violations records.

The outside Background Screening Agency reserve the rights to obtain appropriate information from any individual, corporation or any confidential information deemed necessary to check my credentials and furnish the same to my employer.

I unconditionally release all concerned parties from all liabilities that might arise as a result of my background verification check and also do not hold responsible, any individual, corporation or private and public entity as a consequence of this check.

I also authorize release of this information in original, fax or photocopy form as deemed necessary and authenticate the validity of the same.

Full name of the candidate :

Signature :

Date :

5

To,
HR DEPARTMENT
EDELWEISS LIFE INSURANCE
HEAD OFFICE. MUMBAI.

IRDA CODE DECLARATION

I hereby declare if i possess any such code with other Insurance Companies before joining.

Any other code with Insurance Companies? Yes/No -

If Yes (share code and company name) -

Post joining Edelweiss Life Insurance Company Ltd i authorise the company to check and ascertain if there are any code mapped against me, if any code status is found to be Blacklisted / Suspended / Termination on Regulatory grounds / Fraud" which i have not declared suitable disciplinary action will be taken which may include termination of my services.

I undertake that the information provided by me above are true, complete and correct. I agree and understand that, in the event that company finds at any time, that any information provided by me are false or, misrepresented; the company retains the right to immediately withdraw my offer of job or terminate my job, without notice or compensation.

Full name of the candidate :

Signature :

Date :

6

Annexure 3 - I Declaration cum Undertaking

(To be submitted employees)

To,
The Compliance Officer

Date :

Dear Sir,

Sub: Declaration with regard to dealing in commodities.

With reference to the captioned subject, I hereby declare that:

I have read and understood the Policy governing dealings in commodities by Edelweiss employees and persons to whom this Policy applies (Policy) and I undertake to abide by the same. I also declare that I have not contravened the same in any manner whatsoever.
In case I have access to or receive any "Price Sensitive Information" before the execution of the transaction, I shall inform the Compliance Officer of the change in my position and I shall completely refrain from dealing in such commodities either on my own account or on account of persons to whom this Policy applies.
I have made a full and true disclosure regarding trading accounts and commodity holdings in my name and in the name of persons to whom this Policy applies.
I undertake to obtain prior clearance from the Compliance Officer for all the trades I may execute in my account, or in the account of persons to whom this Policy applies, as per the pre-clearance requirement under the Policy. I undertake to submit duly signed Investment Request Form to the Compliance Officer for approval before placing any order(s) in the commodities as per Policy.
I further undertake not to pass on price sensitive information directly or indirectly to any persons or by way of making a recommendation for the purchase or sale of commodities. I also undertake not to use price sensitive information to buy or sell commodities of any sort, whether for my own account, or for the account of persons to whom this Policy applies.
I indemnify the Edelweiss Group companies and will continue to keep Edelweiss Group companies indemnified against any regulatory action initiated against any of the Companies in the Group on account of my contravention of the rules/regulations and guidelines issued by regulatory agencies in this regard from time to time.

Name of the Employee :

Date of joining :

Name of the Company :

Department :

Signature of the Employee :

7

Employee Code :

Name :

Marital Status :

(To be submitted by employees)

Annexure E

Declaration cum Undertaking

To,
The Compliance Officer
Edelweiss

Date :

Dear Sir,

Sub: Declaration with regard to Insider Trading.

With reference to the captioned subject, I hereby declare that:

I have read and understood the Edelweiss Code of Conduct for Trading in Securities (Other than EFSL Securities) and the Code of Conduct for the Employees of the Group for dealing in securities of EFSL and I undertake to abide by the same. I also declare that I have not contravened the same in any manner whatsoever.
I have read and understood the Securities and Exchange Board of India (Prohibition of Insider Trading) Regulations, 2015 and do confirm & declare that I shall not contravene the same in any manner whatsoever.
In case I have access to or receive any "Unpublished Price Sensitive Information" before the execution of the transaction, I shall inform the Compliance Officer of the change in my position and I shall completely refrain from dealing in the Securities of the Client Company and / or EFSL Securities as applicable, till the time such information becomes public.
I undertake to obtain prior clearance from the Compliance Officer for trades I may execute in my account, my Immediate Relatives' account and in account of my / their Connected Persons as per the pre-clearance requirement under the Code of the Company. I undertake to submit duly signed Investment Request Form to the Compliance Officer for approval before placing any order(s) in the Securities Market, if required.
I undertake to adhere with the minimum holding/contra trade period requirement of the Code.
I undertake to adhere to the provisions of SEBI (Research Analysts) Regulations, 2014 for trading in securities of any listed company for which the research report is prepared or published by me. (Applicable to Research Analyst only).
I further undertake not to pass on any unpublished price sensitive information directly or indirectly to any persons or by way of making a recommendation for the purchase or sell of securities. I also undertake not to use unpublished price sensitive information to buy or sell securities of any sort, whether for my own account, my Immediate Relatives' account, and account of my / their Connected Persons.
I indemnify the Edelweiss Group companies and will continue to keep Edelweiss Group companies indemnified against any regulatory action initiated against any of the Companies in the Group on account of my contravention of the rules/regulations and guidelines issued by regulatory agencies.

Name of the Employee :

Date of joining :

Name of the Company :

Department :

Signature of the Employee :

8

Candidate ID:

Form 'F'
[See Sub-rule (1) of Rule 6]
Nomination

To (Give here name or description of the establishment with full address),

1. Shri/ Shrimati(Name in full here)

Whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).

2. I hereby certify that the person(s) nominated is a /are member(s) of my family within meaning of clause(h) of Section 2 of the Payment of Gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of section 2 of the said Act.

4. [a] My father/mother/parents is/are not dependent on me. [b] My husband's father/mother/parents is/are not dependent on my husband.

5. I have excluded my husband from my family by a notice dated the to the controlling authority in terms of the provision to clause (h) of Section 2 of the said Act.

6. Nomination made herein invalidates my previous nominations.

Nominees(s)

Name in full alongwith full Address of nominees(s). Address write in line below. should be visible	Relationship with the employee	Date of Birth	Proportion by which the gratuity will be shared (%)

9

Candidate ID:

Statement

1. Name of employee

2. Sex

3. Religion

4. Whether unmarried/married/widow/widower

5. Department / Branch / Section where employed

6. Post held with Ticket, or Serial No. if any

7. Date of appointment

8. Permanent Address

Signature or Thumb impression of the Employee

Place :

Date :

Declaration by witness

Nomination signed / thumb-impressed before me

Name in full and full address of the witnesses

1.

2.

Signature of Witnesses

1.

2.

Place :

Date :

Certificate by the Employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment. Employer's Reference No.

Signature of the employer/officer authorized Designation
Name and address of the establishment or Rubber stamp thereof

Acknowledgment by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employee.

Signature of the employee

Date :

10

Candidate ID:

Form - 2 (Revised)
NOMINATION AND DECLARATION FORM
For Unexempted / Exempted Establishment

Declaration and Nomination Form under the Employee's Provident Fund & Employees' Pension Scheme
Paragraph 33 & 61(1) of the Employees' Provident Fund Scheme, 1952 &
Paragraph 18 of the Employees' Pension Scheme, 1995)

1. Name of employee

2. Father's / Husband's Name

3. Date of Birth

4. Sex

5. Marital Status

6. EPF Account No.

7. Permanent Address

8. Temporary Address

PART - A (EPF)

I hereby nominate the Person(s) / Cancel the Nomination made by me previously and Nominate the Person(s), mentioned below to receive the amount standing to my credit in the Employees' Provident Fund, in the event of my death.

Name of the Nominee/s	Address	Nominee's relationship with the Member	Date of Birth	Total amount of share of accumulations in Provident Fund to in paid to each Nominee	If the nominee is a minor, name and relationship & Address of the guardian who may receive the amount during the minority of Nominee

Certified that I have no Family as defined in para 2 (g) of the employees' Provident Fund Scheme, 1952 and should I acquire a family hereafter the above Nominations should be deemed as cancelled
* Certified that my Father / Mother is / are dependent on me

*Strike out whichever is not applicable

Signature or Thumb impression of the Subscriber

11

Candidate ID:

I hereby furnish below particulars of the members of the family who would be eligible to receive Widow / Children Pension in the event of my Death.

Name and Address of the Family Member	Date of Birth	Relationship with Member

*Certified that I have no Family as defined in para 2 (vii) of the Employees' Pension Scheme, 1995 and should I acquire a family hereafter I shall furnish Particulars thereon in the above Form.

I hereby nominate the following person for the monthly Widow Pension [Admissible under para 16 (2) (a) (i) (ii)] in the event of my Death without leaving any eligible Family Member for receiving pension.

Name of the Nominee	Address of Nominee	Date of Birth	Relationship with the Member

*Strike out whichever is not applicable

Signature or Thumb Impression of the subscriber / Employee

CERTIFICATE BY EMPLOYER

Certified that the above Declaration and Nomination has been Signed / Impression before me by employed in my establishment after he / she has read the entries / entries has been read over to him / her by me and got confirmed by him / her.

Place :

Date :

Signature of the Employer or other Authorized Officers of the Establishment

Name and Address of the Factory / Establishment or Rubber Stamp thereof

12

Candidate ID:

ESIC DECLARATION FORM

A. Insured Person's Particulars

ESIC No. of previous employer, if any
Name
Date of Joining
Father's / Husband's name
Date of Birth		Gender
Marital Status		Aadhaar number
Mobile number		Email ID
Current Address
Permanent Address

B. Details of nominee u/s 71 of ESIC Act, 1948 / Rule 56(2) of ESI (Central) Rules, 1950 for payment of cash benefit in the event of death

Full name of nominee
Relationship with member
Current Address
Permanent Address
Date of birth of nominee		Aadhaar no. of nominee
Dispensary Name

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Candidate ID:

C. Family particulars of insured person

Name of family member	Father's / Husband's name	DOB	Relationship with member	Aadhaar no.	Whether residing with him/her		If no, state place of residence
					Yes	No

Signature of the Employee

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New Form : 11 - Declaration Form
(To be retained by the employer for future reference)

EMPLOYEES' PROVIDENT FUND ORGANISATION

Employees' Provident Fund Scheme, 1952 (Paragraph 34 & 57) and
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up Employment in any Establishment on which EPF Scheme, 1952 and for EPS, 1995 is applicable)

1.

Name of Member (Aadhar Name)

2.1

Father's Name

2.2

Spouse's Name (only id married/widow)

3.

Date of Birth (dd/mm/yyyy)

4.

Gender (Male / Female / Transgender)

5.

Marital Status ? (Single/Married/Widow/Widower/Divorcee)

6.

(a) eMail ID

(b) Mobile No (Aadhar Registered)

7.

Whether earlier member of the Employee's Provident Fund Scheme, 1952 ?

8.

Whether earlier member of the Employee's Pension Scheme, 1995 ?

9.

Previous Employment details ? (If Yes, 7 & 8 details above)

a) Universal Account Number (UAN)

b) Previous PF Account Number

c) Date of Exit from previous Employment ? (dd/mm/yyyy)

d) Scheme Certificate No (If issued)

e) Pension Payment Order (PPO) (If issued)

10.

a) International Worker

b) If Yes, state country of origin (name of other country)

c) Passport No.

d) Validity of passport (dd/mm/yyyy) to (dd/mm/yyyy)

11.

KYC Details: (attach self attested copies of following KYC's) — Must Enclose Scan copy for the following documents

a) Bank Account No. & IFS Code

A/c: IFSC:

b) AADHAR Number

c) Permanent Account Number (PAN), If available

12.

First EPF Member Enrolled Date	First Employment EPF Wages	Are you EPF Member before 01/09/2014	If Yes, EPF Amount Withdrawn?	If Yes, EPS (Pension) Amount Withdrawn?	After Sep 2014 earned EPS (Pension) Amount Withdrawn before Join current Employer?

UNDERTAKING

Certified that the particulars are true to the best of my knowledge
I authorise EPFO to use my Aadhar for verification / authentication / eKYC purpose for service delivery
Kindly transfer the fund and service details, if applicable, from the previous PF account as declared above to the present PF account. (The transfer would be possible only if the identified KYC details approved by previous employer has been verified by present employer using his Digital Signature
In case of changes in above details, the same will be intimated to employer at the earliest.

Date :

Place :

Signature of Member

DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms./Mrs. Has joined on and has been alloted PF Number
B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995: ((Post allotment of UAN) The UAN alloted or the member is)
Please Tick the Appropriate Option : The KYC details of the above member in the JAN database

Have not been uploaded Have been uploaded but not approved Have been uploaded and approved with DSC

C. In case the person was earlier a member of EPF Scheme, 1952 and EPS 1995;
The KYC details of the member in the UAN database have been approved with Digital Signature Certificate and transfer request has been generated on portal
As the DSC of establishment are not registered with EPFO, the member has been informed to file physical claim (Form-13) for transfer of funds from his previous establishment.

Date :

Signate of Employer with Seal of Establishment

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Entity : Edelweiss Life Insurance Limited

Employee ID :

Acceptance of Information Security Responsibility

I, working in the capacity of as an employee at Edelweiss Group covering all entities, accept the responsibility of:

Information:

ensuring that I will not disclose Edelweiss or its client specific information intentionally or unintentionally known by me through direct and / or indirect sources. I will ensure that I do not share any confidential / sensitive information physically/ Electronically / verbally.

Physical Access:

using all the physical accesses of the facility provisioned to me judiciously and only to the extent my role requires me to. I will ensure from my side that this privilege is not misused by me, knowingly or unknowingly, allowing unauthorized individuals to enter into the areas of the facility unless authorized by my reporting authority. Further, I shall ensure I wear the access card at all times during my presence in Edelweiss facilities.

Passwords / Pass codes:

ensuring confidentiality of all the passwords / passcodes provided and / or maintained by me. I understand the repercussions of misuse of these and hence will ensure these are safeguarded by me at all times.

Documents

ensuring all documents within the facility accessible to me directly or indirectly will not be misused in any way by me as I understand that these documents are sensitive in nature and can be of importance to the organization.

Incident Reporting:

reporting any anomalous activities observed in the facility which can cause damage to the assets at Edelweiss or cause harm to its employees.

Assistance during situations resulting in Business Continuity invocation:

ensuring my availability during adverse situations that require business continuity. Moreover, in my best efforts, I shall keep the BCP team or my RA informed about any anomalies that could potential be a cause for invoking business continuity management process.

Information Systems:

ensuring judicious usage of all the Information Systems and services (including Internet / Chat services) as per Edelweiss Information Security Policies, if provisioned tome for my role. I am aware that I will not be using these services if these have not been provisioned by my reporting authority at Edelweiss.

If I have any further queries / clarifications concerning the above as applicable tome for myjob, I know I can consult my Reporting Authority or the Chief Information Security Officer (CISO) at Edelweiss.

All documents and data transmitted by you through electronic communication including by way of Whats App to [Edelweiss] will be strictly at your own risk. [Edelweiss] does not give any assurances or warranty, express or implied, as to the privacy or protection of the documents and data conveyed by you electronically and in no event will [Edelweiss] be liable for any loss or damage including without limitation, indirect or consequential loss or damage arising from the loss of privacy arising out of or in connection with the use of electronic communication by you.

Signature :

Place :

16

HIRING TABLE

Candidate name :

Region :

Branch Code :

Designation :

DM Emp Code :

DM Name :

Branch Location :

PAN No. :