Appendix 1 : Transfer of Servicing Form

Attention: Agency Administration

Level 10, Menara Prudential

Transfer of Servicing Request Form

I (policyholder/participant) hereby request to transfer the policy/certificate (s) as stated below to _______________________________
(New Servicing Agent name) ________________________ (New Servicing Agent code)
Policy No. / Certificate No.

Name of Assured/Participant

Contact No.

Reason for Change of Servicing Agent: - ______________________________________________________________________________

___________________________________________________________________ (Compulsory)
___________________________
Signature of Policyholder / Participant

_________________
Date

I (New servicing Agent) _____________________________________hereby agree to service the above-named policyholder/participant.

__________________________
Signature of Agent
Code No.

__________
Date

Note: Only in-force policies are allowed to transfer

Seven (7) policies and above required RDM/SRDMs recommendation

--------------------------------------------------------------------------------------------------------------------------------------------------------For Transfer of Servicing and commission (Applicable under same agency only)
I (existing agent) ____________________________________________ hereby agree to transfer servicing and commission to the abovenamed agent.
___________________________
Signature of Agent
Code No:

__________________________
Endorsed by QL
Name:
Code No.

--------------------------------------------------------------------------------------------------------------------------------------------------------RDM/SRDMs recommendation for transfer for seven (7) policies and above
Justification:

________________________________________________________________________________________

__________________________
RDM/SRDM
Name:
Region

For Office Use Only

Date

_____/_____/_____

To

_________________________________

Agency Code

_________________________________

Branch

_________________________________

Dear Sir / Madam,

We regret to inform you that we are unable to process your request for servicing due to:You are not licensed to service Life/Takaful customers unless you have passed the said examination.
Signature of policyholder/participant is different from our record.
Request for Transfer of Servicing form is incomplete.
QL / Existing agents signature is different from our record.
Policyholder withdraws the request for change of servicing agent.
No signature/justification from RDM/SRDM. (For Seven (7) policies and above)
Others: __________________________________________________________________
___________________________________________________________________

Checked By: __________________

Name:
Date:
Note: Please refer to the next page

Approved By: __________________

Name:
Date: