Memo

To: Leong Mun Yee/ Fione Wong (For All Business Units)
From: Tel No:
Date: Fax No:

Agency Application for PIAM Registration – Inclusion as 2 nd Principal

Agency Name (IN BLOCK):
Introducer Agency (If applicable):

Type of Agency: Sole Proprietorship Partnership Motor Dealer

Sdn Bhd / Bhd Trade Specific Agent – Travel Agent (TSA)
DSO Travel Koperasi

Is this a Life Agent :Y/N

If Y, is this agent a downline of an existing MSIG agent: Y /N
Is the Life Leader of this agent in the “Life Leaders & Life Agents Recruitment Program”?: Y / N
If Y, please provide name of the Life Leader Agent: _____________________________________________

Documents enclosed:-
PIAM Application Form
MSIG Application Form
Privacy Notice
Agent or Corporate Nominee NRIC
Directors and Shareholders NRIC
Bank Account - Giro Fund Transfer / Rentas Form (F-FN-005)
Business Registration Form:
Borang 2 (License from The Ministry of Tourism – Applicable to Trade Specific Agents Only)
Borang 9 / (For East Malaysia) – Trading License
Borang 13 (if any)
Borang A, D or E, where applicable
Goods & Services Tax (GST) Letter / Certificate plus Self-Billing
Statutory Declaration by Corporate Nominee
Registration Fees - Payable to “MSIG Insurance (Malaysia) Bhd.”
RM35.00 – Sole Proprietor
RM50.00 – Others

RECRUITED BY – Account Handler RECOMMENDATIONS / COMMENTS

Name (IN BLOCK) / Signature
Branch / Business Unit
Designation
Date
APPROVAL 1 - Unit Head (If applicable)
Name (IN BLOCK) / Signature
Date
APPROVAL 2 - Branch Head
Name (IN BLOCK) / Signature
Date
APPROVAL 3 – HEAD OFFICE: SVP Biz Ops SVP Branch Operations Support [Tick () where applicable]
Name (IN BLOCK) / Signature
Date
Encl.

APPENDIX 1

F-BD-006-V12
 (THIS FORM MUST BE SUBMITTED IN DUPLICATE)

DECLARATION BY NEW PRINCIPAL

(FOR INCLUSION AS SECOND PRINCIPAL/
CHANGE OF PRINCIPAL)

1. I hereby declare that we MSIG Insurance (Malaysia) Bhd (46983-W) have appointed the
following agent / agency to transact general insurance business on behalf of the company.

Name of Agent / Agency : __________________ (Business Registration No: ___________)

Corporate Nominee : __________________

NRIC No. : __________________

Address of Agent/Agency : __________________

__________________
__________________
__________________

2. The letter of appointment for inclusion as second Principal/release letter by the previous Insurer for
Change of Principal in respect of the above agency is attached for verification by PIAM.

3. We hereby agree that the “Provisional Registration” of the above agency would be effective from
the date of declaration and shall be effective for a period not exceeding three (3) months from the
date hereof except in the event of receipt of a notice from the Registrar that the formal application
for registration has been rejected.

Name of Principal Officer : ________________________

Signature of Principal Officer : ________________________

Date of Declaration : ________________________

PIAM Use Only

Date Received: _______________

Documents:

i) Letter of appointment by 2nd Principal

ii) Letter of Release

“Provisional Registration” is hereby granted from date of Declaration.

__________
Registrar

F-BD-006-V12