License Application Form

REMINDER: PRU LIFE INSURANCE CORPORATION OF U.K.

Please use CAPITAL LETTERS and black ink. 9/F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio,
1634 Taguig City, Philippines
Tick the appropriate box to indicate your choice.
Customer helpdesk: (632) 683 9000, (632) 884 8484, (632) 887 LIFE
within Metro Manila, 1 800 10 PRULINK for domestic toll-free
Email: [email protected] Website: www. prulifeuk.com.ph

AGENT INFORMATION

SURNAME, GIVEN NAME, MIDDLE NAME BRANCH

A PRE-CONTRACT TRAINING REQUIREMENTS

Basic Training Course (BTC)

Traditional Life Review and Traditional Exams and/or Variable Unit-linked Review and Variable Exams
*The sequence of training and exams may be interchanged by branches, depending on the particular situation or need.

B LICENSING REQUIREMENTS (all forms must be in the agent-applicant’s own handwriting and must have identical signatures)
B.1 Requirements for single license application (Traditional/Variable)
Duly filled out Interview Assessment Form (IAF)
Duly filled out Life Stage Financial Planning Assessment Form (LSFP)
Duly filled out and signed License Application Form
Duly filled out and notarized Application for Insurance Agent’s License
Photocopy of any valid government issued ID
Four (4) pieces of identical 1” x 1” pictures (formal setting with red background)
Proof of payment of BTC fee (PhP 500.00) - (BTC fee should be paid in a separate official receipt)
Proof of payment of Licensing Fee (PhP 1,530.00)
Copy of the Insurance Commission (IC) or Insurance Institute for Asia and the Pacific, Inc. (IIAP) exam result for
Traditional/Variable (depending on the license applied for) bearing a passing mark
Social Security Number (SSN) supported by valid proof (e.g. SSS ID, SSS E1 Form, etc.)
Tax Identification Number (TIN) supported by valid proof (e.g. TIN card, BIR Forms stamped/received by BIR, Company ID, etc.)
Photocopy of a Bank of the Philippine Islands (BPI) Automated Teller Machine card (front and back), under the name of the agent-applicant
Duly filled out and signed Career Agent’s Master Agreement (CAMA) – signed on all pages (2 sets)
Duly filled out and signed Agency Standards BTC 101 Handouts Acknowledgement Form
B.2 Requirements for additional type of license (Traditional/Variable)
Duly filled out and notarized Application for Insurance Agent’s License
Photocopy of any valid government issued ID
Two (2) pieces of identical 1” x 1” pictures (formal setting with red background)
Proof of payment of Licensing Fee (PhP 1,530.00)
Copy of the IC or IIAP exam result for Traditional/Variable (depending on the license applied for) bearing a passing mark
Social Security Number (SSN) supported by valid proof (e.g. SSS ID, SSS E1 Form, etc.)

C ADDITIONAL REQUIREMENTS (as applicable)

For naturalized citizen: For foreigners:
Photocopy of Certificate of Naturalization Photocopy of Alien Certificate of Registration (ACR)
Photocopy of Immigrant Certificate of Residence (ICR)

For government employees: For previously licensed agents in another life insurance company:
Original copy of clearance/permission from the head Clearance from previous company
of the department or agency (in accordance with
Certificate of Authority License Number issued by the Insurance Commission
Section 18 of Rule 13 of Civil Service Commission
Memorandum Circular No. 15-1999) Photocopy of Professional Tax Receipt (PTR) for the current year

Note: If the agent-applicant is applying for two (2) licenses simultaneously, the agent-applicant must submit the requirements listed in Sections A, B.1,B.2 and C above, as applicable.

FOR AGENCY LICENSING USE ONLY

Received by and date: BTC Record and Non-Medical Remarks:
Authority (NMA) Score:

Approved by and date: Client number:

Processed by and date Processed by and date Agent code:

(Life Asia): (NACS):

DIST/LAF/IT/08/23/19
 PERSONAL INFORMATION SHEET
Please use block letters on all pages. Any alterations must be made in the agent-applicant’s own handwriting and must be countersigned. Use available spaces below the text
boxes if the details/characters do not fit in the row provided.

SURNAME

GIVEN NAME

MIDDLE NAME

RESIDENCE ADDRESS (House no.,building, street, village, baranggay, town, province)

COUNTRY ZIP CODE MOBILE NUMBER RESIDENCE PHONE NUMBER BUSINESS PHONE NUMBER

CURRENT AND/OR PREVIOUS ASSOCIATION WITH ANY FINANCIAL INSTITUTION

(position includes but is not limited to being an agent, owner, business representative, broker, etc. – start with the most recent)

INCLUSIVE DATES (FROM –TO)

COMPANY/BUSINESS NAME POSITION
MM/DD/YYYY

1.

2.

3.

EMERGENCY CONTACT DETAILS

SURNAME, GIVEN NAME, MIDDLE NAME

RELATIONSHIP TO APPLICANT TELEPHONE NUMBER MOBILE NUMBER

ADDRESS

Attach 1x1 photos

1x1 1x1 1x1 1x1 1x1 1x1 1x1

PHOTO PHOTO PHOTO PHOTO PHOTO PHOTO PHOTO

I hereby certify that all of the above statements and answers are complete and true.
Signature over printed name of Agent-applicant DATE OF SIGNING (mm/dd/yyyy)

FOR AGENCY LICENSING USE ONLY

Evaluated by: Date evaluated: Remarks:

Amended by: Date amended:

DIST/LAF/IT/08/23/19
 DECLARATION OF UNDERSTANDING AND INTEREST
1. This is to formalize my intention to join Pru Life UK as:
Agent Unit Manager Branch Manager

BRANCH NAME

COMPLETE NAME OF RECRUITER RECRUITER’S AGENT CODE

2. I undertake to accomplish the following:

2.1. completion of the training courses required by Pru Life UK,
2.2. passing of the licensure exam conducted by the IC or other duly authorized testing agencies,
2.3. filing of the life insurance agent's license application, and
2.4. submission of all of the requirements mandated by Pru Life UK and/or the IC
I acknowledge that the foregoing are pre-requisites for my appointment as an agent of Pru Life UK.

3. I acknowledge that I am not allowed to act and agree not to act as an agent of Pru Life UK until my appointment as such takes effect in accordance with the provisions of
a duly executed Career Agent’s Master Agreement with said Company.

4. This Declaration shall be sufficient evidence of the relationship between myself and the abovenamed Recruiter.

5. Any claim or dispute arising from any declaration in this form shall be subject to the assessment, evaluation and final determination of Pru Life UK.

6. I hereby acknowledge and understand that for as long as I am an agent of Pru Life UK, I am mandated to disclose the identity of any family member and/or close associate
having business interests in and/or financial connections with Pru Life UK either as an agent, employee, or vendor to avoid any potential conflict of interest that may arise
within Pru Life UK.

NAME DUTIES OR DESIGNATION RELATIONSHIP TO APPLICANT

7. I hereby certify that to the best of my knowledge, I have disclosed all my business interests, financial connections, and professional affiliations which may be deemed as
competing directly or indirectly with Pru Life UK’s business.

8. I hereby certify that I have never filed for bankruptcy and have not been declared bankrupt.

9. I hereby certify that I have no pending administrative and/or criminal case before any court/authorized body. I, further, certify that I have never been found guilty/convicted
of any administrative offense and/or crime.

10. I will indemnify Pru Life UK and hold it free and harmless for any damages incurred by Pru Life UK in relation to a breach of any of the warranties above or for any damages
arising from any misrepresentation made in this form or from any material breach of its provisions.

11. I hereby affirm that the information given in this form is true and correct and that I have not withheld anything that could affect the contract I would be entering with
Pru Life UK.

Signature over printed name of Agent-applicant DATE OF SIGNING (mm/dd/yyyy)

Signature over printed name of Immediate Manager DATE OF SIGNING (mm/dd/yyyy)

DIST/LAF/IT/08/23/19
 ANTI-MONEY LAUDERING (AML) AND COUNTER TERRORIST FINANCING (CTF) QUESTIONNAIRE
If you answer “NO” to any question, please provide any clarification or additional information at the portion provided in this questionnaire. On items with
selection, please shade the appropriate circle.

A AWARENESS

1. Are you aware of the responsibilities of an agent pursuant to the Anti-Money Laundering Act (AMLA), as
Yes No
amended?

2. Are you aware of the Know-Your-Customer (KYC)/Customer Due Diligence (CDD) requirements of AMLA, as
Yes No
amended?

3. Are you aware of the reporting requirements on suspicious transactions of AMLA, as amended? Yes No

4. Are you aware of the record keeping requirements of AMLA, as amended? Yes No

B DUE DILIGENCE

5. Have you been involved in any crime within the last twelve (12) months from the date of this application? Yes No

If yes, please provide a brief description as well as the current status or outcome of the case:

6. Do you have any pending case in court within the last twelve (12) months from the date of this application? Yes No

If yes, please provide a brief description as well as the current status or outcome of the case:

7. Have you had any contractual relationship with a company/entity that was severed due to fraud,
misrepresentation, estafa, swindling, or other forms of deceit on your part? Yes No

If yes, please provide a brief description on the outcome of the severance of contractual relationship.

C TRAINING

8. Were you able to complete the BTC – Compliance Courses and Examinations? (For Applicants) Yes No

If yes, please provide date:

9. Were you able to complete the Annual Refresher on Compliance Courses Training and Examinations? Yes No
(For Existing Agents)

If yes, please provide date:

CLARIFICATIONS FOR ITEMS WITH “NO” ANSWER

D DECLARATION
I hereby declare that the information given above is true and accurate to the best of my knowledge and that Pru Life UK is entitled to rely fully on such
information and representation, and I agree that this questionnaire shall form part of my application/renewal as agent.

Signature over printed name of Agent-applicant DATE OF SIGNING (mm/dd/yyyy)

DIST/LAF/IT/08/23/19
 PURPOSE STATEMENT

The information provided by you in this application form will be used for application and general data processing to be done by Pru Life UK.
This processing may be either manual or automated, and shall include:

background investigation conducted in connection with your application and/or appointment

as agent of Pru Life UK;

agency administration, including but not limited to, payment of commissions and
other benefits;

performance management;

grievance handling and execution of disciplinary processes;

internal and external communications;

communicating with your designated contacts, in case of an emergency;

official travel arrangements;

keeping agent records and carrying out other internal business administration; and

fulfillment of legal obligations.

We may share your personal information within the Prudential Group and with our accredited third-party service providers as provided on our
website (https://www.prulifeuk.com.ph/en/footer/privacy-policy/), for any of the purposes set out above.

We may also share your information to governmental and other regulatory authorities or self-regulatory bodies in various jurisdictions as mandated
by applicable laws and regulations, including the Data Privacy Act of 2012, the Anti-Money Laundering Act of 2001, the E-Commerce Act of 2000,
the Philippine AIDS Prevention and Control Act, the Magna Carta for Disabled Persons, Presidential Decree No. 1718, and any other applicable data
protection legislation from time to time in force (“Data Privacy Laws”).

Any information collected may be retained by Pru Life UK until ten (10) years from termination of the agency or date of denial of this application,
whichever comes earlier.

By checking the boxes below, you:

allow Pru Life UK to process your personal information and sensitive information, within or outside of the Philippines, in accordance with
the Data Privacy Act and its implementing rules and regulations. The processing activities will be for purposes mentioned above.

warrant that the consent of your character references, previous employers, emergency contacts, and all other data subjects whose
information you have provided to us by reason of your application or in relation to your appointment as agent has been obtained for
the purposes mentioned above. You also undertake to provide Pru Life UK with proof of your authority to provide the required consents
of the aforementioned data subjects with respect to the disclosure and processing of their personal information and/or sensitive personal
information for the purposes set forth above.
You agree to indemnify Pru Life UK and hold it free and harmless from any damages incurred by Pru Life UK in relation to a breach of any of the
warranties above or for any damages arising from any misrepresentation made in this form or from any material breach of its provisions.
To know more how information on how we will protect your information, you may access our privacy policy through our website at
(https://www.prulifeuk.com.ph/en/footer/privacy-policy/). Should you have any questions or request in relation to the processing of your personal or
sensitive personal information, or your rights as a data subject as listed within NPC and Data Privacy Act, you may get in touch with our Data
Protection Officer through the following:

Postal address: 9F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio, 1634 Taguig City, Metro Manila
Telephone: (+632) 887 LIFE (887 5433) for Metro Manila, 1 800 10 PRULINK (1 800 10 7785465) via PLDT landline for
domestic toll-free
Email: [email protected]

DECLARATION
You declare that the statements and answers you provided on this application form are complete and true. Further, you agree that if you have given
any misleading, false or untrue statement, Pru Life UK can immediately withdraw the offer, or if you have already been appointed as an agent, terminate
your agency contract.

Signature over printed name of Agent-applicant DATE OF SIGNING (mm/dd/yyyy)

DIST/LAF/IT/08/23/19
 Department of Finance
INSURANCE COMMISSION

APPLICATION FOR INSURANCE AGENT’S LICENSE

(Under Chapter IV, Title I of the Insurance Code)

To the Insurance Commissioner:

The undersigned hereby applies for a license under the provisions of Chapter IV, Title I of the Insurance
Code, to act as insurance/general agent of PRU LIFE INSURANCE CORPORATION OF U.K. in respect of the
kind of insurance indicated herein:

NON-LIFE LIFE VARIABLE LIFE ACCIDENT AND HEALTH

Others (please specify)

and for that purpose submits the following statements and information required herein.

(Agency Name if any)

1. Name of applicant:
(Surname) (First Name) (Middle Name)

2. Agent type: Ordinary Agent (___) General Agent (___)

3. Home address:
Business address:
T I N: Email address:
Mobile number:
4. Birth a) Date: b) Place:

5. Citizenship: Sex: Civil status:

6. If married, a) Maiden Name:

b) Husband’s Name:

7. If naturalized citizen of the Philippines, give date and place of naturalization and attach photocopy of certificate
of naturalization.

FOR IC USE ONLY

Verified by: Date: Processed by: Date:
Approved by: Date:

License Fee: OR No. Date: CA No.

REMARKS:

PAGE 1
Application for Insurance Agent’s License
Insurance Commission

8. If applicant is a foreigner, give serial number, date and place of issue of alien certificate of registration
(ACR) and the immigrant certificate of residence (ICR) for the current year and attach photocopy of
each thereof
9. If applicant is a partnership, association or corporation:
a) Attach a certified true copy of the certificate of registration, articles of partnership,
association or incorporation and by-laws:
b) State percentage of Filipino participation in the partnership, association or corporation:

10. Any license previously granted to act as insurance/general agent in this country? State name of insurance
company represented.

11. Have you filed your income tax return for the preceding year? If not give reason.

12. In the blanks below, state your last (2) employers.

Name of Employer Position Inclusive Dates

13. Are you an official or an employee of an insurance company or broker? If yes, give the position held.

14. Are you a government employee? If yes, attach the necessary clearance/permission from the Head of
the Department or Agency in accordance with Section 18, of Memorandum Circular No. 15, series of 1999 of
the Civil Service Commission.

Executed this day of 20 , at

,Philippines.

Applicant

PAGE 2
Application for Insurance Agent’s License
Insurance Commission

AFFIDAVIT OF VERIFICATION

Republic of the Philippines

Province/City of S.S.

I, , being duly sworn, depose and say that I am the person named in and
who signed the foregoing application that I know the contents thereof and the statements made and answers to
question therein are true.

Affiant

TIN

SSS No.

SUBSCRIBED AND SWORN TO before me this day of 20 ,

Affiant/s exhibited to me his/her issued on
20 , at .

Doc. No. ______ Notary Public

Page No. ______
Book No. ______
Series of 20 ______

APPROVED AND COUNTERSIGNED for PRU LIFE INSURANCE CORPORATION OF U.K.

for the solicitation or procurement of application for life/variable/non-life insurance

Authorized Representative of the Company

Note: This form may be revised without prior notice.

PAGE 3
Application for Insurance Agent’s License
Insurance Commission

CERTIFICATE OF WAIVER

WE HEREBY CERTIFY:

That we know the applicant ________________________________, that a thorough investigation has been made into
his/her character, conduct and fitness; he/she is of good moral character and worthy of a Certificate of Authority, and that
he/she has had experience in each of the kinds of insurance he/she proposes to write or solicit under the Certificate of
Authority applied for.

That we have communicated with the former and present employees of the applicant and the replies have been satisfactory.

That to the best of our knowledge, information and belief, all statements and answer contained in the application have been in
the handwriting of the applicant with respect to the questions applicable to him/her.

If and when the agency is terminated, written notice thereof will be given forthwith to the Insurance Commission together with
the reason therefore.

In consideration of the Certificate of Authority to be issued to the above-mentioned applicant, under the provision of Section
299 of the Insurance Code, we hereby waive, on behalf of —

Pru Life Insurance Corporation of U.K.

(Company Name)
the right to appeal to the Secretary of Finance in case of revocation by the Insurance Commissioner of the
certificate to be issued in favor of the above-mentioned applicant and agree to cancel at once the contract of
agency between said applicant and the company upon receipt of the notice of revocation.

Executed in _____________ on _______________.

TIN: 004-661-494

By _______________________________
Authorized Representative of the Company

N.B. No person, partnership, association or corporation required by Law to file an income tax return shall be issued a license
to engage in any trade, business or occupation to practice a profession unless he shall have presented to the officer issuing
such license or permit proof that he has filed his income tax return during the preceding year and that income taxes due have
been paid thereon. For the purpose of this Act, a copy of such income tax return on which is shown a certification or state-
ment by the Collector of Internal Revenue or his duty authorized representative that the aforesaid income tax return, and the
corresponding receipts showing payment of all income taxes due thereon, shall be sufficient proof.

Any person, partnership, association or corporation who obtains a license mentioned in the preceding paragraph without
presenting the aforementioned certification of the Collector of Internal Revenue or his duly authorized representative, under
the pretext that he or it is not required by law to file an income tax return when in truth he or it is so required, or under any
other misrepresentation, shall be liable to fine of not more than Five Hundred Pesos, or imprisonment of not more than one
year or both, in the discretion of the Court. In case of partnership, association, the manager or the equivalent officer thereof
shall be held responsible and in addition, the license shall be revoked. (Section 1, Republic Act No. 1538)

IC-LLI-DP-002-F-01
Rev.1
PAGE 4