www.libertyinsurance.com.sg
Information of Applicant
Name of Applicant:
NRIC/FIN No.:
________________________________________________________________ _______________________________
Nationality:
Date of Birth:
GIA No. (if applicable):
_______________________________ _______________________________ _______________________________
Residential Address:
________________________________________________________________ Postal Code
(
)
(
)
Business Address (if any):
________________________________________________________________ Postal Code
Contact No.:
Gender:
_______________________________  Male
Preferred Mailing Address:
 Business
 Female
 Residential
Information of Individual Agent
Academic Qualification:
 3 „O‟ Levels
 „A‟ Levels
 Degree
 Diploma
 Others:
_____________________________
 BCP
 COMGI
 CGI
 PGI
 HI
 Others:
____________________________
General Insurance Certification:
Please select the Type of Agent (by default of cash, unless specified):
 Cash
 Credit
For Credit Agent only:
Name of Bank:
Bank Branch:
Bank Account No.:
_______________________________ _______________________________ _______________________________
Date of Check:
Check No.:
Amount of GIA Fee Payable:
_______________________________ _______________________________ _______________________________
CASH AGENT: “A Cash Agent is one who does not have a Principal‟s Account and who does not receive any cheques made payable to
the agent. The cheque is made payable to the insurance company and likewise, any cash is to be handed over directly to the insurance
company.”
CREDIT AGENT: “ A Credit Agent is one who operates a Principal‟s Account and who receives cheques made payable in the name of
the agent (and also cash) and these cheques are then banked into the Principal‟s Account of this agent.”
Details of past work experience including insurance experience
Name of Employer
Year
Joined
Year Left
Position Held
Type of Employer
Business
Liberty Insurance Pte Ltd (Registration No. 199002791D) │ GST Registration No. M2-0093571-3
51 Club Street #03-00 Liberty House Singapore 069428 │ Tel: 1800-LIBERTY (5423 789)│ Fax: (+65) 6223 6434
06/2014
Page 1 of 4
Name of Principals currently representing
Name of Primary Principal
Name of Secondary Principal 1
Name of Secondary Principal 2
If you are currently representing three principals and intend to replace/terminate one of the above, please indicate which
principal you wish to terminate (if applicable):____________________________________________________________
Other Information
1. Has the agent been terminated/rejected by other insurers?
If Yes please state the reason:
________________________________________________________

Yes

No
2. Has the agent been taken to court before?
If Yes, please state the reason:
___________________________________________________________

Yes

No
Information of Additional Nominee Agents
Name of Additional Nominee Agent:
NRIC/FIN No.:
________________________________________________________________ _______________________________
Date of Birth:
Nationality:
Gender:
_______________________________ _______________________________  Male
Academic Qualification:
 3 „O‟ Levels
 „A‟ Levels
 Female
 Degree
 Diploma
 Others:
_____________________________
 PGI
 CGI
 COMGI
 Others:
_____________________________
General Insurance Certification:
 BCP
 HI
Total years of experience in General Insurance?
__________________________ years
Total years of experience in Life Insurance?
__________________________ years
Name of Life Insurance company currently representing (if applicable)
 AIA
 AXA
 Great Eastern
 Manulife
 Prudential
 Tokio Marine
 Others:
_______________________
Details of past work experiences including insurance experience
Employer
Year
Joined
Year Left
Position Held
Type of Employer
Business
Liberty Insurance Pte Ltd (Registration No. 199002791D) │ GST Registration No. M2-0093571-3
51 Club Street #03-00 Liberty House Singapore 069428 │ Tel: 1800-LIBERTY (542 3789)│ Fax: (+65) 6223 6434
06/2014
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Declaration
1. I/We hereby declare as follows:
1.1 I/We have entered into an agency agreement or agreements with an Ordinary Member or Members of GIA, none
of which has been terminated over the last 12 months.
1.2 I/We have not convicted of:
a) An offence under the Insurance Act (Chapter 142) or any other regulations made thereunder;
b) An offence under the Penal Code (Chapter 224);
c) An offence under any Act or regulations administrated by the Monetary Authority of Singapore;
d) A criminal offence involving fraud, misrepresentation or dishonesty; or
e) An offence under any statute which is an re-enactment Act, repealing Act or a consolidation Act in respect of
any of the legislations referred
1.3 I/We are not:
a) The subject of criminal proceedings which are pending in Court;
b) The subject of any investigation or disciplinary proceedings carried out by the Agents‟ Registration Board;
c) The subject of any investigation or disciplinary proceedings carried out by the Monetary Authority of
Singapore or by any governmental or regulatory body acting under any act or subsidiary legislation hereinafter
referred to as “any Regulator”;
d) The subject of a prohibition order or any order made by the Monetary Authority of Singapore or any Regulator;
e) The subject of a written warning, reprimand or censure meted out by the Monetary Authority of Singapore or
any Regulator; or
f) A shareholder, partner, manager, employee or director of any business registered with the Registry of
Business or of any company registered with the Registry of Companies in respect of which:
i. The business/company has been censured or disciplined; or
ii. The business or business license has been suspended or revoked by the Monetary Authority of Singapore
or any regulator.
1.4 I/We are in compliance with and not in breach of any of the provisions of:
a. The General Insurance Agents‟ Registration Regulations;
b. The Code of Practice of Agents; and
c. The Singapore General Insurance Code of Practice.
1.5 I/We are not an undischarged bankrupt or a person in respect of whom bankruptcy proceeding is pending in Court
1.6 We are not (in the case of a company registered with the Registry of Companies) the subject of:
a. A winding up order;
b. A judicial management order; or in respect of which
c. A receiver has been appointed (whether by the Court or otherwise); or
d. An application or petition for winding up, or appointment of judicial manager or appointment of receiver has
been filed in Court and is pending;
1.7 I/We have not:
a. Entered into a composition or a scheme of arrangement with creditor; or
b. One or more outstanding judgments against me/us which has/have been unsatisfied within 7 days from the
date of judgment;
1.8 I have (in the case of an agent) fulfilled the minimum number of hours required as may be determined by IA from
time to time.
2. We hereby further declare that:
2.1 Our minimum paid up capital is S$25,000 (applicable to a company or partnership business registered with the
Registry of Companies); and
2.2 All our shareholders, partners, managers, employees or directors who act on our behalf or represent us in our
business of general insurance agents are also registered with the Agents‟ Registration Board as Nominee Agents
and that all the declarations stated herein are true and correct in respect of our Nominee Agents, mutatis
mutandis.
3. I/We hereby agree and undertake that I/we shall immediately notify in writing the Agents‟ Registration Board of GIA
and the Ordinary Members of GIA for whom I/we represent as my/our Principals in the event that any fact, event or
matter arises or occurs after the making of this Declaration which renders any of declaration herein contained untrue or
incorrect.
4. I/We hereby:
4.1 Declare that the information and statements given in this application and any accompanying attachments are
correct and true;
4.2 understand and accept that Liberty Insurance Pte Ltd reserves the right to cancel my/our application or terminate
my/our agency representation if any of the information furnished above is found to be false, incorrect or
misrepresented or of fraudulent means.
Liberty Insurance Pte Ltd (Registration No. 199002791D) │ GST Registration No. M2-0093571-3
51 Club Street #03-00 Liberty House Singapore 069428 │ Tel: 1800-LIBERTY (5423 789)│ Fax: (+65) 6223 6434
06/2014
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Declaration
5. Liberty Insurance Pte Ltd (“LIPL”), may/are permitted to collect, use, disclose and/or process my personal
data/personal information set out in this form and any other personal information about me that is provided by me or
possessed by LIPL (whether now or in the future) (collectively the “Personal Information”) and disclose and transfer
such Personal Information to the General Insurance Association of Singapore (“GIA”), the Agents‟ Registration Board
(“ARB”) and the Monetary Authority of Singapore and any other insurer or company operating insurance business in
Singapore, for the purpose(s) of:
5.1 processing my application to be an agent with LIPL;
5.2 managing, facilitating and/or administering my business relationship with LIPL in accordance with my obligations
as a registered general insurance agent with the General Insurance Association of Singapore, Agents
Registration Board and my obligations under my agreement with LIPL;
5.3 storing, hosting, backing-up (whether for disaster recovery or otherwise), my Personal Information, whether
within or outside Singapore;
5.4 marketing my services as an insurance agent, to the public or to any third party;
5.5 showcasing or marketing my achievements in relation to my insurance transactions such as but not limited to
publication of my image and personal data on public media platforms such as the newspaper, the Internet, LIPL
in-house notice boards, at marketing exhibitions, the radio etc;
5.6 considering, proposing, facilitating or sending me for any training that LIPL or GIA, as the case may be,
determines is suitable for me;
5.7 disclosure of my personal data to the Inland Revenue Authority of Singapore to facilitate or administer tax related
requirements, claims, deductions or matters;
5.8 disclosure of my personal data to a credit monitoring bureau on a monthly basis (or whenever necessary) to
check on issuance of any bankruptcy petition or order against me;
5.9 carrying out due diligence or other screening activities (such as background checks) in accordance with legal or
regulatory requirements or risk management procedures required by the Monetary Authority of Singapore or that
have been put in place by LIPL or GIA;
5.10 dealing in any matters relating to, arising from or connected with my relationship with LIPL (including but not
limited to the mailing of correspondence, statements, invoices, reports or notices to me, which could involve
disclosure of certain personal data about me to bring about delivery of the same as well as on the external cover
of envelopes/mail packages), contacting me on matters related to or connected to my relationship with LIPL);
and
5.11 complying with applicable law in administering and managing my relationship with LIPL.
(collectively the “Purposes”)
6. Any other insurer or company operating insurance business in Singapore (collectively “Other Insurers”) may/can
collect (and LIPL may disclose to them), may use, disclose (including disclosure by such Other Insurer to LIPL) and/or
process my Personal Information for one or more of the above Purposes; and
7. my Personal Information may/can be disclosed by LIPL, to third parties including related corporations or associated
companies, third party service providers or agents, which may be sited in or outside of Singapore, for one or more of
the above Purposes;
8. LIPL may/will also be collecting from sources other than myself, personal data about me, for one or more of the above
Purposes, and thereafter using, disclosing and/or processing such personal data for one or more of the above
Purposes.
Name and NRIC/FIN No.
Signature
Main Applicant/Authorized Officer
Nominee Agent
Signature of Approval by Chief Executive Officer of the new representation
Name of Insurance Company:
_______________________________
Date
________________________________________________________________
_______________________________
Signature of Chief Executive Officer
Name: Luiz Campos
Liberty Insurance Pte Ltd (Registration No. 199002791D) │ GST Registration No. M2-0093571-3
51 Club Street #03-00 Liberty House Singapore 069428 │ Tel: 1800-LIBERTY (5423 789)│ Fax: (+65) 6223 6434
06/2014
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