AGENCY APPLICATION FORM

2 Coloured Photos
FOR OFFICIAL USE ONLY
35mm x 45mm
Interviewer: Interview Date/Time: (NOTE: Male Applicant MUST wear tie)

IAC No.:

Appointment Date: Day Month Year

1. All relevant parts of this Application Form must be completed in the Applicant's own handwriting.
2. This application is valid for one year from the date of submission, after which a fresh Application Form must be submitted.
3. Please tick where appropriate or indicate "NA" for any question which is not applicable.
4. Please attach an addendum, if there is insufficient space.
5. The Company reserves the right to terminate the agency of the applicant, if any information provided in this Form is found to be untrue.

Appointment type:
New Appointment Re-appointment Direct Appointment to
other Ranks _________________

Joining as: Full-time Part-time

PART I: APPLICANT'S PARTICULARS

Name as in NRIC (underline surname): Mr Mrs Miss Mdm

Preferred Name: Name in Chinese Character:

(if applicable)

NRIC No.: S / T * please circle accordingly Nationality: Singaporean Gender: Male Date of Birth:
Others Female

NRIC Colour: Pink Singapore PR: Yes Please indicate expiry date of Re-entry permit
Blue No (dd/mm/yyyy)

Race: Chinese Eurasian Religion: Buddhist Muslim

Malay Others Christian Others
Indian Hindu

Preferred Language: English Marital Status: Single

(Please rank 1 being most Mandarin Married
preferred)
Malay (Bahasa) Divorced
Tamil Widowed
Others Separated

PART II: CONTACT DETAILS

Residential Home Address (as in NRIC) Correspondence Address

House/Block: House/Block:

Street: Street:

Level & Unit: Level & Unit:

Building Name: Building Name:

Postal Code: Postal Code:

Contact Number Email Address

Home:

Mobile:

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 PART III: QUALIFICATIONS (Educational & Professional)
Month / Year Month / Year
Qualification (e.g. Diploma in Engineering) Institution / Country Commenced Completed

Insurance Qualifications (Check one or more boxes that apply)

M5 (year obtained) M8 M9
Certificate in Health Insurance Certificate in General Insurance Others

PART IV: APPLICANT'S BACKGROUND (To be fully completed. Indicate "NA" for sections not applicable)

Please attach separate list if space below is insufficient

Employment History (Please state in chronological order, starting with the current employer)
From To Basic Salary Commission
mm/yy mm/yy Company/Country Last Position Held (if applicable) (if applicable) Reasons for leaving

Insurance Background (Please state all life and general insurance experience)
From To Basic Salary Commission
mm/yy mm/yy Name of Insurance Company Last Position Held (if applicable) (if applicable) Reasons for leaving

Immediate Family Members' Particulars (If single, please list parents' & siblings' particulars. If married, please list spouse's & children's particulars)
Full Name NRIC/Passport No. Nationality Date of Birth Relationship Occupation Name & Place of Employment

Professional Club Memberships

Association/Club/Society/Company Period Position Held
From To

Referees (List 2 referees whom you have known for at least 3 years; excluding relatives, Company and agency staff)
Name of Referee Contact No. Occupation Relationship Years known

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National Service (If Applicable)
Service Status: Enlistment Date: ORD:
Completed / Deferred / Exempted *please circle accordingly Vocation: Rank at ORD:

NS Unit:
Reason for Deferment/Exemption
If SAF personnel, please state:
Status: Regular / Full Time NS *please circle

Others

Applicant's Background (Additional Information)

Please indicate "Yes" or "No" for the following questions Yes/No If "Yes", please provide details
1. Are you under any financial obligations such as serving a bond, taken a loan, acted as a
guarantor (surety) for a personal or corporate loan or having an unsatisfied judgement debt?
2. Have you been a director or partner of a company that has gone into insolvency, liquidation
or administration?
3. Have you or your spouse been adjudicated a bankrupt?
4. Have you been convicted of any criminal offence in Singapore or overseas?
5. Has any criminal proceeding been taken or pending against you or your spouse?
6. Has criminal investigation or action of whatever nature been taken against you even though
it may not have resulted in any criminal proceedings?
7. Have you ever consumed any form of illicit drugs, or suffered from substance abuse or
alcoholism?
8. During the last five years, have you received any medical or surgical attention, other than for
minor ailments?
9. Have you applied to join any agency with Great Eastern Life less than six months ago? If
yes, please state date and name of agency.
10. Have you been the subject of any disciplinary investigation or complaint, relating to activities
that are regulated by MAS or under any law in any jurisdiction?
11. Have you been dismissed or asked to resign from office, employment, a position of trust or a
fiduciary appointment or similar position whether in Singapore or elsewhere?
DECLARATION
I hereby declare to the best of my knowledge and belief that all the particulars given by me in this form and attachment (if any) are true, correct and complete. I
also agree that, if any information is false in any aspect, Great Eastern Life Assurance Co Ltd (the Company) shall have the right to terminate the Agency
Agreement (if granted), immediately without any reference to me.

Signature of Applicant Date

PART V: BANK ACCOUNT DETAILS

Direct Crediting of Commission Income into the following Bank Account (A Photocopy of Bank Account Passbook/Statement is required)

Name of Bank: For Official Use Only:

Branch Code/Name: Bank Code:

Account Number: Branch Code:

Account Nature: Savings Account / Current Account *please circle accordingly

I agree that:

1. if for any reason whatsoever, the amount due to me is not credited into my Bank Account on the date as specified in my commission statement, I shall not hold the
Company, responsible;
2. the Company reserves the right to recover any amounts credited in error into my Bank Account;
3. if warranted, the Company reserves the right to stop the crediting of commission; and
4. any changes in the particulars of the Bank Account must be given in writing to the company.

Signature of Applicant Date

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 PART VI: REPORT (To be completed by Agency Personnel)
Introducing Officer (LPR / ELP / SEL) *please circle accordingly

Name:

IAC No: Signature / Date:

Immediate Officer's Report (AM / MNR / SMR / GMR) * please circle accordingly
1. How did you get to know the applicant?
Personal: Policyholder Family/Friends
Life Planner: Policyholder Family/Friends
Event: Career/Campus Fair Roadshow
Others: Walk-in/Call-in Advertisement Agency Campus Activities
(please state)

2. How long have you known the applicant?

Year(s) Month(s)

3. Have you interviewed the applicant? If yes, please state the date(s).

4. With reference to Part IV Applicant's Background (Additional Information), please provide further information if any answer is "Yes".

5. Any other relevant information to support this application.

Name:

IAC No: Signature / Date:

Contact No. (HP/Office): Mailbox No.:

Group Manager's Report

Comments:

Name:

IAC No: Signature / Date:

Please ensure that this application is submitted together with a copy of applicant's NRIC (for Singaporeans), Entry and Re-entry Permit (for PRs), education certificates,
CMFAS Module 5, 9 and Health Insurance certificates, account passbook showing account number and type (Current/Savings), and form AA6 if applicant is an
ex-agent of another life insurance company. ORIGINALS (EXCEPT FOR ACCOUNT PASSBOOK) MUST BE PROVIDED FOR VERIFICATION .

For Official Use Only - Approval of Application

Comments: Comments:

Approved Approved
Rejected Rejected
Referred to:

Signature / Date: Signature / Date:

Name: Name:

Date: Date:

The Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)
Mailing Address: 1 Pickering Street #13-01 Great Eastern Centre Singapore 048659
Tel 6248 2000 Fax 6532 2214 Website www.lifeisgreat.com.sg

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