Great Eastern PicellsiGreat GREAT EASTERN LIFE ASSURANCE (MALAYSIA) BERHAD 2, Application for Change of Servicing Agent Form Tre New Senin Ages equres to eu ths form, nee has Ben compte, oe Agency Adnsaon Departmen, the rleven Business Davolopmnent anager enment! IAD (93745-A) {A Pollcynolders Details and request i Name: NRIC No! Address: eee | hereby request to transfer the policy ‘certificates (s) listed below to a new servicing agent of my choice, Name an (Account Number), No. [Life Assured 7 2 3 Policy Number 8. Reason for Request: (Please tick ¥ whichever is applicable.) ) OPersonal Reason(s); |) C1 Poor or no servicing from the current servicing agent. Please stale your feedback eS tt) (Other reasons: a | hereby confirm that | am making this request of my own free will without the prior interference of any party, Policyholders Signature Date _ (Mote: Your request fora change of servicing agent willbe processed wihin 21 workings deys and you wil be noted othe ‘outcome of your reques!) C. Acceptance by New Servicing Agent: | hereby confirm that agree to accept the transfer of the policy (ies) listed above and stall render my service to the Pelcyholder understand that the Company reserves the right fo take action deemed necessary against me upon ‘any breach of the Company's Agency Rules and Regulations New Servicing Agent Date Name: AIC No, IMPORTANT NOTE - This form is only applicable for: i) The transfer of policy which are stil in-force, |i) Anvexisting agent wo has an ‘active’ status with the Company. ‘AAD-COAForm-V1-082015, Scanned with CamScanner