COLLECTION CENTER

JOINING FORM

JOIN THE MASS INSURANCE NETWORK Be a part of our trusted insurance collection partner network.

MASS INSURANCE
COLLECTION CENTER Trusted Partner
Trusted Service

₹

ATTRACTIVE
COMMISSIONHigh & timely
commission

◆

FREE TRAINING
& SUPPORTComplete training
and support

▣

EASY PORTALSimple portal
for collections
& reports

✓

TRUSTED
BRANDGrow with a
trusted brand

◉

24X7
SUPPORTAlways here to
help you

1. CENTER DETAILS

Center Name / Shop Name *

Center Type *

CSC Center Cyber Café Online Service Center Other

Address *

City / Town *

District *

State *

Pincode *

Landmark

2. OWNER / CONTACT PERSON DETAILS

Owner Name *

Father / Spouse Name *

Date of Birth *

Mobile Number *

Email ID

Alternate Mobile Number

+91

3. BUSINESS DETAILS

Year of Establishment *

Nature of Business *

GST Number (If Applicable)

Average Monthly Footfall (Approx.) *

4. BANK DETAILS

Bank Name *

Account Holder Name *

Account Number *

IFSC Code *

Account Type *

Saving Current

DECLARATION

I hereby declare that the above information is true and correct to the best of my knowledge.
I agree to abide by the terms and conditions of MASS Insurance Broking Services.

Place *

Date *

Signature / Stamp *

5. DOCUMENTS CHECKLIST

📄 Please attach clear photocopies of the
documents listed below.

Aadhaar Card (Owner) *

PAN Card (Owner) *

Business Address Proof *
(Rent Agreement / Electricity Bill / Shop Act)

Bank Passbook / Cancelled Cheque *

Shop / Center Photo *
(With Board / Signage)

GST Certificate (If Applicable)

6. PORTAL ACCESS DETAILS (For Office Use)

Center Code

User ID

Password

Assigned Executive

Joining Date

SUBMIT YOUR APPLICATION

Email: partners@massinsurance.in

WhatsApp: +91 88661 66107

Helpline: +91 88661 66107