Important Notes 6 AGENT REGISTRATION NO. cael ‘For PIAM Use Only) Ay PERSATUAN INSURAN AM MALAYSIA (General Insurance Association of Malaysia) APPLICATION FORM. FOR THE REGISTRATION OF GENERAL INSURANCE AGENTS e type or write particulars in BLOCK CAPITALS, Applicants are required to fill in or tick the appropriate boxes provided in this form. All items must be completed. Where items are not applicable please indicate with “N/A”. Applicants are required to complete the Declaration of Observance of the “Code of Practice for all Intermediaries” and return the said declaration together with the completed application form. All completed applications must be submitted through the principal. Direct submissions of by the agent to PAM will NOT be entertained. applicatio Applicants with two principals must submit SEPARATE application forms for each principal which are duly certified by their respective principals. Payment of RMI5.00 PER APPLICATION (Non-Refundable and Non-Transferable) must be made payable to “PERSATUAN INSURAN AM MALAYSIA" as processing fee for this application. Cash and Agent’s Personal Cheques will not be accepted Alll general correspondence from PIAM will be directed to the principal in the application form only.PERSATUAN INSURAN AM MALAYSIA (General Insurance Association of Malaysia) APPLICATION FORM FOR THE REGISTRATION OF GENERAL INSURANCE AGENTS. 1 NAME OF AGENT / AGENCY I 2, BUSINESS / COMPANY REGISTRATION NO. ~ a (Please enclose duly certified copies of Business Registration Certificate/Certificate of Incorporation) 3. BUSINESS I ADDRESS - = 4, POSTCODE 5. TOWN rT 6. STATE : LI *7.NAME OF CORPORATE NOMINEE 8. NRIC NO. OF OLD PT" AGENT / CORPORATE NO: NOMINEE, NEW > a no. LI ttttttit 9. DATE OF BIRTH OF AGENT/ CORPORATE NOMINEE 10, GENDER OF AGENT / CORPORATE NOMINEE, mate {_] — [_] remate RACE OF AGENT ConPorarEnommes =; Matay [J CL] inpian cunnese | OTHERS12, INSURANCE QUALIFICATION AND EXPERIENCE OF AGENT / CORPORATE NOMINEE a) Minimum Insurance Qualification (Tick (W ) appropriate box) YES NO 1) Pre-Contract Examination For Insurance Agents (PCEIA) ii) Certificate of Proficiency in General Insurance (CPG!) iii) General Insurance Agents’ Course ~ Certificate of Attendance (Please enclose duly certified copy of the certificate) Explanatory Notes #7; For a Sole-Proprietorship, the corporate nominee must be the sole-proprietor himself For a partnership, the corporate nominee must be one of the partners. b) Other Insurance Qualification of Agent / Comporate Nominee. (Please state accordingly) (Please enclose duly certified copy of the certificate) ©) Educational Qualification of Agent / Corporate Nomince. ick (W ) appropriate box} Primary oO HSC / STPM. CJ LCE J SRP /PMR HIGHER EDUCATION - at (eg. DIPLOMA / DEGREE) MCE / SPM ) State the year you joined as a General Insurance Agent 13, PARTICULARS OF AGENCY IA] CORPORATE STATUS (Tick (7 ) appropriate box) Individual Public Company Sole Proprietorship Cooperative / Society / Club Partnership Others (Please Specify). Private Limited Company{B] FOR A PARTNERSHIP Details of Partners (Continue on separate sheet if more than five) : NAME OF PARTNER OLD NRIC NO, NEW NRIC NO. IC] FOR CORPORATE AGENCY {i) Details of Directors (Continue on separate sheet if more than five) : (Please enclose duly certified copies of Form 49) NAME OF DIRECTORS ‘OLD NRIC NO. NEW NRIC NO. }) Details of Shareholders (Continue on separate sheet if more than five) (Please enclose duly certified copies of Form 24/Form 32A) NRIC NO. Busivess / company} “MOUNT % NAME OF SHAREHOLDERS —~} REGISTRATION sHare. | SHARE: OLD No. | NEW NO. NO. HoLbNG | HOLDING *[D] AUTHORISED SHARE CAPITAL: RM “{F) PAID.UP SHARE CAPITAL RM I“14, DETAILS OF SENIOR MANAGEMENT. POSITION E r NAME OLD NRIC NO. | NEW NRIC NO, a Explanatory Notes: “13: (D) and (B) Private Limited Company and Public Company are required to complete these sections. “14 Refers (o Executive Chairman, Fxecutive/Managing Director, Chief Executive Officer, General Manager and Senior Executive of Corporate Agency 15. TYPE OF GUARANTEE PROVIDED @ wo @ Period of Guarantee Type of Amount of From To «Guarantee Provided Guarantee 2M) | Hay Mon Your’) Day” Monts” You (Civic CW ) appropriate box) » nan [] same fi) Third -—} Relationship vary L_] rocTwea ray Guarantor wrescot [| ronaes* C] N.B. If amount of guarantee provided to the principal is “UNLIMITED” please specify “UNLIMITED” in column 2.16. DECLARATION BY AGEN’ We hereby declare that: a, W/We have no other insurance related business interest(s). (Please note that in the event you have or acquire other insurance related business interest(s), these must be declared in writing to the Board). b. I/We are not and will not become without the prior approval of the Agency Affairs Sub- Committee (“the Board”) an employee or a director of or a shareholder or debenture holder in or have any interest in any other company or firm which is formed for the purpose of transacting any form of insurance business including insurance broking and loss adjusting. (This prohibition does not apply to the company for which I/ We act or a company whose shares are listed on the Kuala Lumpur Stock Exchange.) ¢. We being a Corporate Agency have not employed and will not employ anyone who is an employee or @ director of or a shareholder or debenture holder in or has any interest in another Corporate Agency. (This prohibition does not apply to the company for which we act ‘ora company whose shares are listed on the Kuala Lumpur Exchange), d. V/We have not: - (been convicted of criminal misappropriation, criminal breach of trust, cheating ot forgery or abetment of or attempt to commit any such offence. i) been convicted of fraud, dishonesty or misrepresentation against any insurance company or against any person having official dealings with any insurance company. ii) been declared a bankrupt or insolvent. ¢. We do not have outstanding premium debts or other financial obligations with any insurer with whom I/We previously had an agency agreement. I consent to PIAM processing my personal data as provided in this form or hereafter for purposes in connection with my registration as an insurance agent, regulation of insurance agents by PIAM and for establishing a shared database of agents (collectively, “Purpose”), including the disclosure of my personal data to affiliates which may be located outside Malaysia and third parties including LIAM and MTA for the Purpose. I acknowledge that:~ (it will be necessary for PIAM to process my personal data for the Purpose, without which I will not be able to register as an insurance agent, andfi) I may make inguiries or complaints, and access or correct my personal data or limit the processing thetoof by contacting PIAM via AIA Bhd. Email: agyadmin.queries@aia- Bremier.cot ty &. If in completing this form or hereafter, 1 have or will provide any personal data of other identifiable individuals, T confirm that I have informed them about the Purposes for which and the manner in which their personal data will be collected and. processed by PIAM, given them the other information set in clause 16(£) above, and secured their agrecment to PIAM processing, disclosing and transferring their personal data. SIGNATURE 2 NAME OF AGENT/AGENCY AGENT/AGENCY STAMP DATE a17. UNDERTAKINGS BY AGENT:- We hereby undertake: a. To notify the Registrar in writing, through my/our respective Principals, whenever there has been any change in the comporate information, name or address or when /We commence or cease to represent any general insurance company within one (1) week of such change occuring, b. Not to engage in any agency operations or transactions until We have been duly issued with a Certificate of Registration by the Board, : ©. To abide by the General Insurance Agents” Registration Regulations. SIGNATURE NAME OF AGENT/ AGENCY AGENT/AGENCY STAMP : DATE Rebel 18, CERTIFICATION BY PRINCIPAL >~ T hereby certify that this application is complete and the information given herein in respect of our interests have been verified by an authorised personnel of the company and found to be true and correct, AUTHORISED: SIGNATORY DESIGNATION ; COMPANY Ie HEE eee DATE eee eee