AFFIX

PHOTOGRAPH
APPLICATION FOR EMPLOYMENT HERE

POSITION APPLIED :
SOURCE:
1. NAME FATHER / HUSBAND'S NAME :

Surname Middle First

2. DATE OF BIRTH (DD/MM/YYYY): GENDER :
MARITAL STATUS :
BIRTH STATE: BIRTH COUNTRY:
IDENTIFICATION MARK :
NATIONALITY: BLOOD GROUP:

3. PRESENT ADDRESS:(Complete address with detailed nearest landmark, street name) CONTACT NO. &
EMAIL: (specify
code)

CITY:
STATE:
PIN CODE:
4. PERMANENT ADDRESS (Complete address with detailed nearest landmark, street name) CONTACT NO. &
EMAIL: (specify
code)

CITY:
STATE:
PIN CODE:
5. HAVE YOU BEEN INTERVIEWED BY ICICI LOMBARD OR ANY OF ICICI GROUP COMPANY? IF YES, NAME OF THE COMPANY
OUTCOME:

6. DO YOU SUFFER FROM ANY HEALTH PROBLEMS? IF YES, PLEASE SPECIFY:

DIFFERENTLY ABLED (Please Specify):

7. HAVE YOU BEEN CRIMINALLY PROSECUTED OR HAVE ANY POLICE OR LEGAL CASE GOING ON AGAINST YOU OR FILED
BY YOU? PLEASE GIVE DETAILS:

8. EDUCATIONAL QUALIFICATIONS: (Staring from S.S.C.)

Year
Exam Board / University / Institute Class/Marks Obtained Main Subjects
Passed

Date: Place: Signature :

 FAMILY DETAILS:

FAMILY MEMBERS NAME OCCUPATION QUALIFICATION AGE

FATHER

MOTHER

SPOUSE

CHILD (With name

specify if son or
daughter)
CHILD (With name
specify if son or
daughter)

DETAILS OF WORK EXPERIENCE:

TOTAL YEARS OF WORK EXPERINECE _______________________
Please record your experience details in chronological order starting from present/last employment (If you are currently working, please
mention the duration as Ex:- 21 Oct 2015 to till date):

CURRENT EMPLOYMENT - NAME & ADDRESS OF

COMPANY PERIOD OF STAY HR CONTACT DETAILS
FROM (DD/MM/YYYY): (PH NO. & OFFICIAL
EMAIL ID)

TO (DD/MM/YYYY) / TILL
1 DATE :

REASON FOR LEAVING:

LAST DRAWN CTC (p.a):
EMP CODE:
DESIGNATION:
PREVIOUS EMPLOYMENT - NAME & ADDRESS OF
COMPANY PERIOD OF STAY HR CONTACT DETAILS
FROM (DD/MM/YYYY) (PH NO. & OFFICIAL
EMAIL ID)
TO (DD/MM/YYYY)

LAST DRAWN CTC (p.a):

REASON FOR LEAVING:
EMP CODE:
DESIGNATION:

SL LAST LAST PLACE OF DATE OF DATE OF REASON FOR

COMPANY NAME
NO DESIGNATION POSTING JOINING SEPERATION SEPERATION

Date: Place : Signature :

 GIVE 2 REFERENCES OF IMMEDIATE SUPERVISORS IN CURRENT ORGANIZATION WHOM WE CAN REFER FOR
VERFICATION INDICATING THEIR POSITION AT WORK:
1 TEL No:
OFFICIAL EMAIL ID:
2 TEL No:
OFFICIAL EMAIL ID :
GIVE 2 REFERENCES OF IMMEDIATE SUPERVISORS IN PREVIOUS ORGANIZATION WHOM WE CAN REFER FOR
VERFICATION INDICATING THEIR POSITION AT WORK:
1 TEL No:
OFFICIAL EMAIL ID:
2 TEL No:
OFFICIAL EMAIL ID :

PLEASE CONFIRM IF ANY FAMILY MEMBER (INCLUDING RELATIVES) IS CURRENTLY EMPLOYED WITH ICICI LOMBARD
OR ICICI GROUP OR HAS ANY BUSINESS ASSOCIATION WITH ICICI GROUP:
1 RELATIONSHIP :
TEL No:
OFFICIAL EMAIL ID:
2 RELATIONSHIP :
TEL No:
OFFICIAL EMAIL ID :
3 RELATIONSHIP :
TEL No:
OFFICIAL EMAIL ID:

First Choice Second Choice

LOCATION PREFERENCE

LANGUAGES KNOWN

LICENSES AND CERTIFICATES(If Any)

HONORS AND AWARDS(If Any)

JOB TRAININGS (If Any)

DECLARATION

With reference to my application for an appointment in the services of ICICI General Insurance Company Limited
(Company), I hereby declare and undertake the followings:

There is no case pending against me in any Court of Law or in any Police Station. Further, there was no FIR/
Investigation against me in the past and I was never arrested and or convicted in any Court of Law.

If yes, please mention details of such pending case(s) and or reasons leading to such FIR / Investigation / arrest /
conviction in the past including period of detention, if any

Date: Place : Signature :

 Declaration and Authorization

I hereby authorize ICICI Lombard GIC Ltd (Or a third party agent appointed by the Company) to contact any former
employers as indicated above and carry out all background check not restricted to education and employment deemed
appropriate through this selection procedure. I authorize former employers, agencies, educational institutes etc. to
release any information pertaining to my employment/education and I release them from any liability in doing so.
I confirm that the above information is correct to the best of my knowledge and I understand that any misrepresentation
of information on this application form, in the event of my obtaining employment, may result in action based on
Company policy.

Signature:

Name:

Date:

PAN No: