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New Application Form

- Introduction and Guide

New Business Department

May 2013
AIA confidential and proprietary information. Not for distribution.

AGENDA

Introduction

Step by Step Application Guide

Compulsory document(s) for hardcopy submission

AIA confidential and proprietary information. Not for distribution.

01

Introduction

AIA confidential and proprietary information. Not for distribution.

Introduction

New application form will be available to agency force from June 17, 2013
onwards

Form Version is OPUNI01.06313

Submission must be original application form. Photocopy /self printed is not


allowed.

Total 12 pages for application form with sections breakdown below:


General Information (Policy number, Agent info etc.)

A. Personal Details
B. Payment Details
C1. Details of Insurance Applied for Traditional/ Investment Link
D. Other Insurance Details
E. Important Notice
F. Nominations
G. Details of Proposed Insured/ Covered Members
H. Lifestyle and Health Details
Authorization & Agents Declaration (Signature section)
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02

Step by Step Application


Guide

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Insurance Application Form (General Information)


Start filling up application form-- indicate Policy number, Collection
station and Agent details under General Information section.

Corporate No.

Only Worksite Marketing (WSM) plan required Corporate No.

Collection Station

Indicate branch code for policy contract collection

Policy Number

Policy number of the case [10 digits]

Medical/ Non Medical

To indicate NB application under Medical type or Non Medical

Agency Code

Agency code of the case

Agency Name

Name of agency

Agent Code1

Agent code of the case

Agent Name 1

Name of Agent 1

Agent 1 Mobile No

Contact number of Agent 1

Agent 1 E-mail Address

Email address of Agent 1

Agent 2 details

Applicable to Share Agent case. 2nd agent to fill up all the details of agent 2.

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Insurance Application Form (General Information)


Special request under General Information is an Optional field,
depends on clients request.

Special Request (Optional)

Optional field, depends on clients request

Policy Dating

If client request for backdating, indicate the backdating date here

Conversion

Applicable to Conversion case only, indicate the sum assured and policy number to be converted

Age admission

To tick if client request for age admission

Medical Exam done on

Indicate the date of examination done for current case (if any)
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A. Personal Detail
To fill up clients details under A .Personal detail section.

A.PERSONAL DETAIL

Proposed Insured

Applicant, if other than Proposed Insured

Name as shown on IC/Passport

Name of proposed insured

Name of applicant owner (for 3rd party case)

Compulsory field for 3rd party case


e.g. Parent, spouse, legal guardian, employer etc.

Relationship to Proposed Insured


New IC No.

New IC No. of proposed insured

New IC No. of applicant owner

Old IC No/Birth Certificate No.**

Old IC No/Birth Certificate No. of proposed insured

Old IC No/Birth Certificate No. of applicant owner

Army No./Police No./Passport


No.**

Army No./Police No./Passport No of proposed


insured

Army No./Police No./Passport No of applicant


owner

Co. Registration no.

Compulsory if Applicant is Corporate/Company

** Not a compulsory field if New IC no. is provided.


AIA confidential and proprietary information. Not for distribution.

A. Personal Detail

A.PERSONAL DETAIL

Proposed Insured

Gender

Clients Gender info [ Male / Female]

Race

Clients Race info [ Malay / Chinese / Indian etc.]

Religion

Clients Religion info [ To choose either Muslim or Non-Muslim ]

Nationality

Clients nationality info [ Malaysian / Singaporean / Australian etc. ]

Permanent Resident of

Clients country of permanent residency

Date of Birth

Clients D.O.B [ in MM/DD/YYYY format ]

Age

Client Age last birthday (ALB)

Marital Status

Clients marital status [ Single / Married / Widowed / Divorced ]

AIA confidential and proprietary information. Not for distribution.

Applicant, if other than Proposed Insured

A. Personal Detail

A.PERSONAL DETAIL

Proposed Insured

Correspondence Address

To select mailing address either Residence or Office address

Residential Address

Clients residential address

Office Address

Clients office address

Telephone No.

Residence / Office / Mobile / Fax [ Please complete at least one ]

A.PERSONAL DETAIL

Proposed Insured

E-mail Address

Clients E-mail address [ e.g. Johndoe@gmail.com ]

Applicant, if other than Proposed Insured

AIA confidential and proprietary information. Not for distribution.

A. Personal Detail

A.PERSONAL DETAIL

Proposed Insured

Applicant, if other than Proposed Insured

Name of Employer

Proposed insureds employer name

Applicant owners employer name

Nature of Business

Indicate nature of business of proposed insured

Indicate nature of business of applicant owner

Occupation & Exact Duties

Indicate occupation name and exact nature of work


for proposed insured

Indicate occupation name and exact nature of


work for applicant owner

Occupation Class

Indicate occupation class of proposed insured


[ class 1 or 2 or 3 or 4 ]

Indicate occupation class of applicant owner


[ class 1 or 2 or 3 or 4 ]

Annual Earned Income

Select annual income range of proposed insured


* To specify amount if income >RM250,000

Select annual income range of applicant owner


* To specify amount if income >RM250,000
10

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B. Payment Details
To fill up payment frequency and payment method under B. Payment
details section.

B. PAYMENT DETAILS

Mode of Payment

Select ONE of the paymode. [ Annually / Semi-annually / Quarterly / Monthly ]

Method of Payment

Select ONE of the payment method.

Direct Pay

Cash / Cheque
For Cheque, premium payment is to Self, spouse, children and parents only

Auto pay

If AutoPay is selected, please submit AutoPay / FPX Direct Debit Form

Credit card

If credit card is selected , to fill Credit cards details under B.2

Payroll Deduction

ONLY applicable to Worksite marketing (WSM) plan


11

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B. Payment Details

CREDIT CARD DETAILS


Cardmember Account No

16 digits of credit card number

Card Expiry Date

Expiry date of the credit card

Issued by

Credit card issuing bank

Cardmember's Name

Name as shown on credit card

Telephone No

Contact number of cardmember

Cardmembers relationship to Proposed Insured

Allowable Cardmembers relationship : Self, Spouse, Children and Parents only

12

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C1. Details of Insurance Applied for


Fill up the plan information applied under section C1.
Basic plan on the Left and Rider(s) on the Right.

13

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C1. Details of Insurance Applied for


Indicate the Basic plan info (Name & amount) under correct plan category.
Refer table below for basic plan category.
Par, Non Par and Medical plans are not allowed to submit together under one
proposal.
If proposed insured apply
Basic plan below
a

Plan Category
a

A-EnrichMax OR
A-Enrich20 OR

Participating Plan

A-Life CriticalCare
A-LifeSecure OR
b

WSM A-LifeSecure OR

Non-Participating Plan

A-LifeProtect Term
* Term OR Term to Age
c

A-LifeLink

Investment-Linked Plan

Medical Plan

A-Life Med Regular OR


WSM A-Life Med Regular
d
14

AIA confidential and proprietary information. Not for distribution.

C1. Details of Insurance Applied for


Select rider(s) if any . Refer table below for respective rider description.
Attachable Riders

Riders Description

APDC

A-Plus DisabilityCare (Purchasable )

APW

A-Plus Waiver

APP

A-Plus Payor

APPC

A-Plus PayorCI

APCC (OL)

A-Plus CriticalCare (Traditional)

APHI

A-Plus HospitalIncome

APTAS

A-Plus Total AccidentShield


* Tick option RCC if you wish to apply Riot And Civil
Commotion benefit.

APAS

A-Plus AccidentShield
* Tick option RCC if you wish to apply Riot And Civil
Commotion benefit.

APMED

A-Plus Med (for Insured only)


* *Tick option Spouse or/and Children if you wish to
cover family member(s).

APCC (IL)

A-Plus CriticalCare (Investment-Linked)


*** Tick ONE option to cover up to AGE 70 or AGE100

APWE

A-Plus WaiverExtra
*** Tick ONE option to cover up to AGE 70 or AGE100

APMCC

A-Plus Multi CriticalCare

APECC

A-Plus Early CriticalCare

APPE

A-Plus PayorExtra

APHIE

A-Plus Hospitalincome Extra

*
*
**
**
***
***

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15

Investment-Linked Insurance Details


For ILP plan, Investment Linked fund details and payment option is
required.
2
Fund Allocation
Premium
Payment
Option

1 -Maximum 10 funds
can be selected &
must be in multiple
of 5%.
-The total sum must
be at 100%
-Indicate A-Plus
Saver Premium
amount if you wish
to apply
- The selection of
fund(s) for Regular
Premium & A-Plus
Saver Premium will
be the same.

Ad Hoc Top up
Not applicable at
NB until further
notice.

AIA confidential and proprietary information. Not for distribution.

To authorize
company to
deduct
Policy
Charge
Deduction
from
Savings
Account (APlus Saver
Premium).

E
BL
A
LIC
P
P
TA
O
N
16

Details of Premium Payment Option (Life Insurance Only)


Applicable to Traditional plan only.

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17

Details of Premium Payment Option (Life Insurance Only)


Future Premium Deposit Fund (FPDF)
Client to indicate the Single /Lumpsum payment
amount if he/she wish to apply FPDF.
Deposit of Annual /Semi-annual /Quarter
payment is not applicable until further notice.

BLE
A
C
PLI
P
TA
NO

Basic plans which allow Future Premium


Deposit Fund
o
o
o
o
o
o

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A-EnrichMax
A-Enrich20
A-Life CriticalCare
A-LifeSecure
WSM A-LifeSecure
A-LifeProtectTerm

18

Details of Premium Payment Option (Life Insurance Only)


Dividends and/or Guaranteed Cash Payments Option.
Required to fill up if Basic plan applied as per Table below :
Basic
Plan

Dividens

Guaranteed Cash
Payments

A-EnrichMax

2 options for selection :


Cash Payment Option OR
Cash Accumulation Option

2 options for selection :


Cash Payment Option OR
Cash Accumulation Option

A-Enrich20

2 options for selection :


Cash Payment Option OR
Cash Accumulation Option

2 options for selection :


Cash Payment Option OR
Cash Accumulation Option

A-Life
CriticalCare

2 options for selection :


Cash Payment Option OR
Cash Accumulation Option

Not applicable

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19

D. Other Insurance Details

Other Insurance Details

Compulsory field

Insuring Company

To indicate the name of company

Life /Critical Illness /Health /Accident

To specify the insurance coverage type

Sum Assured (RM)

To indicate the insurance covered sum assured amount

Year Issued

To indicate the issue year of insurance covered

If no insurance coverage with other company, indicate NIL under Insuring Company column.
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D. Other Insurance Details


Applicable for Juvenile Application :
Other Insurance details - Indicate the insurance coverage with
other company if any (For Applicant owner , Parent and siblings).
Contingent owner details is required.

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21

E. Important Notice
Replacement of existing policies.
Client is required to answer Q1 and Q2 under Important notice section.

2
3

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22

E. Important Notice

Important Notice
Q3. US Citizen / US PR

Please provide Taxpayer ID if client is Citizen /Permanent Resident of USA

AIAs promotion information

Please tick if you wish to receive information regarding AIAs promotions and offers

Print Policy Contract in

2 Options. Select either [English] OR [Bahasa Malaysia].


Note : If this section is blank, policy contract will be printed and issued in English

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23

F. Nominations
Select 1 of the 4 options under nomination section.

Option

Description

No nomination is made.

No nomination

For Non Muslim nomination:


a) If you are a married NON-MUSLIM and your nominee is your spouse, child; or
2

Section 166

b) If you are a NON-MUSLIM and you are neither married nor have any children, and your
nominee is your parent;

Section 163/167

For Muslim nomination.


For Non-Muslim nomination ,other than (a) and (b) in Section 166

Section 166 & Sec.163/167 combined

Combination of section 166 & 163/167

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F. Nominations
Fill up nominee details (if any)
Name, Address, % of share, IC No, DOB and Relationship to Insured.
Total % of share must be 100%
Fill up Trustee details (if any)
Name, IC No and Address.

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25

G. Details of Proposed Insured/ Covered Members


Q1(a) and Q1(b) Applicable to proposed insured.
Q2(a) and Q2(b) Applicable to applicant owner who apply payer
benefit rider.

Details of Proposed Insured and Applicant Owner


1(a) Height & Weight of Proposed Insured

Compulsory field .

1(b) Name and Address of Proposed Insureds physician of


last consultation

Indicate doctors name and clinic address for last doctors visit.

2(a) Height & Weight of Applicant-Owner

Compulsory field for client who apply payer benefit rider.

1(b) Name and Address of Applicant Owners physician of last


consultation

Indicate doctors name and clinic address for last doctors visit.

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G. Details of Proposed Insured/ Covered Members


Fill up Spouse details if medical plan covers spouse is applied.
Fill up Child details if medical plan covers child is applied.
Maximum 4 children to be covered

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27

H. Lifestyle And Health Details


Answer all the Lifestyle Questions (Q1-Q10) under Section H.
To provide full particulars if answer to any question (1 to 10) is Yes.
[Refer Q11-page 10 of application form.]

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28

Authorization & Agents Declaration


Complete the application form with Signature, signing place and
date.

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29

03

Compulsory document(s)
for hardcopy submission

AIA confidential and proprietary information. Not for distribution.

Compulsory document(s) for hardcopy submission


Traditional /Investment Link Plan

Application form
Important Notice to Clients

Standalone Medical Plan

Application form
Important Notice to Clients

Disclosure of Intermediarys
status
Clients choice *

Confirmation Of Advice
SQS (Quotation) with signature
Copy of IC

Disclosure of Intermediarys
status
Clients choice *

Confirmation Of Advice
Copy of IC

* Clients choice

Compulsory document

(1) I/We wish to disclose ALL information


requested for in this Form.

FHR booklet is required

(2) I/We wish to disclose PARTIALLY


information requested for in this Form.

Customer Fact-Find Form

(3) I/We wish to receive the product information


only and DO NOT WISH to disclose any
information requested for in this Form.

No document is required

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