ApplicationformGuide 1 PDF

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
01
Introduction
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)
02
Step by Step Application

Guide
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.
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)
6
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.

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 ]
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 ]
A. Personal Detail
A.PERSONAL DETAIL
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
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
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
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

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

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
*
*
**
**
***
***
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.
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.
17

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
A-EnrichMax
A-Enrich20
A-Life CriticalCare
A-LifeSecure
WSM A-LifeSecure
A-LifeProtectTerm
18

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

A-Enrich20


A-Life
CriticalCare

Not applicable
19
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.
20

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.
21
E. Important Notice
Replacement of existing policies.
Client is required to answer Q1 and Q2 under Important notice section.
2
3
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
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
24
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.
25

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.
26

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
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.]
28
Authorization & Agents Declaration

Complete the application form with Signature, signing place and
date.
29
03
Compulsory document(s)
for hardcopy submission
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
31
32

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New Application Form

- Introduction and Guide

New Business Department

Step by Step Application Guide

Compulsory document(s) for hardcopy submission

AIA confidential and proprietary information. Not for distribution.

AIA confidential and proprietary information. Not for distribution.

Form Version is OPUNI01.06313

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

Total 12 pages for application form with sections breakdown below:

Step by Step Application

AIA confidential and proprietary information. Not for distribution.

Insurance Application Form (General Information)

Only Worksite Marketing (WSM) plan required Corporate No.

Indicate branch code for policy contract collection

Policy number of the case [10 digits]

Medical/ Non Medical

To indicate NB application under Medical type or Non Medical

Agency code of the case

Agent code of the case

Contact number of Agent 1

Agent 1 E-mail Address

Email address of Agent 1

AIA confidential and proprietary information. Not for distribution.

Insurance Application Form (General Information)

Special Request (Optional)

Optional field, depends on clients request

If client request for backdating, indicate the backdating date here

To tick if client request for age admission

Medical Exam done on

AIA confidential and proprietary information. Not for distribution.

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

Relationship to Proposed Insured

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

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

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

Co. Registration no.

Compulsory if Applicant is Corporate/Company

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

Clients Gender info [ Male / Female]

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

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

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

Clients country of permanent residency

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

Client Age last birthday (ALB)

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

AIA confidential and proprietary information. Not for distribution.

Applicant, if other than Proposed Insured

To select mailing address either Residence or Office address

Clients residential address

Clients office address

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