1.
Section 1 is to be completed by policyholder
Attention To CONSERVATION UNIT Date :
Untuk Perhatian Tarikh
Name of Assured/Life Assured
Nama Pemunya Polis/Hayat Diinsuranskan
Policy Number
Nombor Polisi
Telephone Number
Nombor Telefon
Dear Sir / Madam,
Tuan / Puan,
Signature of Assured
Tandatangan Pemunya Polisi
Section 2 is to be completed by new servicing agent
Signature of New Servicing Agent
Tandatangan Ejen baru
Section 3 is to be completed by QL (please tick whichever applicable)
I am agreeable to the transfer of servicing only
I am agreeable to the transfer of servicing and commission
Signature of Quality Leader of terminated agent
T/tangan Quality Leader ejen yang diberhentikan
Agency Code/Kod Ejen :
I refer to your letter notifying that my servicing agent, Mr./Mrs._________________________,
(Agent Code :____________) has resigned his / her duties as an agent with Prudential. I hereby agree
to appoint Mr. / Mrs ________________ (Agent Code :______________).
Saya merujuk surat tuan yang menyatakan ejen saya, En./Cik ___________________________,
(Kod Ejen :___________) telah menamatkan perkhidmatannya sebagai ejen Prudential. Dengan ini
saya melantik En./Cik ____________________, (Kod Ejen :___________) selaku ejen insurans saya
dan beliau telah menghubungi serta bersetuju menguruskan hal ehwal insurans saya.
POLICYHOLDER'S CONSENT FORM - APPOINTMENT OF NEW AGENT
PERSETUJUAN PEMEGANG POLISI - PERLANTIKAN EJEN BARU
11401003
TOP/T/Ver 08.2006