GENERAL INSURANCE ASSOCIATION OF SINGAPORE (GIA)
APPLICATION FOR REGISTRATION AS AN INDIVIDUAL GENERAL INSURANCE
AGENT
INDIVIDUAL APPLICANT
SECTION I (To be completed and keyed in for all individual applicants)
1. Name of Individual Applicant :
Sex :
NRIC/Passport No :
(Pink/Blue) :
Business Address :
Postal Code :
Correspondence Address :
Postal Code :
Tel Number (Office) :
(Home) :
Pager No. :
Handphone No. :
Telex Number :
Fax Number :
2. Please indicate the name of the nominated Principal you have appointed for collection of the registration
card/certificate of registration. If you have already nominated a Principal previously, that Principal will
continue to be your nominated principal unless the Principal representation with your nominated Principal has
been terminated. If so, please nominate another principal and indicate below : -
Name of *new/existing nominated Principal :
SECTION II (To be completed and keyed in for all individual applicants)
1. If the Applicant or anyone of its sub-agents has any other business interest or employment relating to insurance,
please give the following particulars : -
(a) Name of Person :
Name of Business :
Type of Business :
Nature of Interest/Position Held :
Business/Company Registration No :
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[Notes to Question 2]
Identification and Qualification of the Agent
You are required to read the instructions carefully and answer all questions.
(a) The identification and qualification of the individual who provide technical advice on insurance matters must be
given.
(b) All sub-agents must be identified and their qualification must also be provided.
(c) The academic qualifications for all persons requiring registration cards must be filled in :
B - Below GCE ‘N’ level
N - GCE ‘N’ level
O - GCE ‘O’ level
A - GCE ‘A’ level or Higher School Certificate
P - Polytechnic or similar
U - Tertiary level and beyond
T - Other (please specify)
(d) The professional insurance qualifications, a copy of which should be enclosed :
CGI - Certificate in General Insurance (Singapore)
ACII - Associate of the Chartered Insurance Institute
FCII - Fellow of the Chartered Insurance Institute
AAII - Associate of the Australian Insurance Institute
FAII - Fellow of the Australian Insurance Institute
O - Others (please specify)
(e) Use the following codes for the various position : -
AG - Agent
SA - Sub-Agent
(f) State the number of years of experience in handling general insurance with name(s) of insurance company(ies),
agency(ies), broking firm(s) and dates.
(g) Please note that all registered cardholders have to indicate whether they are full or part time agents and they are
to state the % of revenue / salary derived from general insurance business. A full-time agent is defined as one
who derives the bulk of say 70% or more, of its revenue from selling general insurance. Please use the
following codes :
FT - Full-time agents
PT – Part-time agents
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2. (To be completed by all registered cardholders)
Please ensure that you have read the instructions before filling in the following : -
(a) Name :
Sex :
NRIC/Passport No. :
Date of Birth :
Academic Qualification :
Professional Qualification :
Current Position :
Position [AG/SA] :
Total Years of Experience :
Full time/Part time [FT/PT] :
% of revenue/salary derived from general insurance business :
Details of Experience in insurance companies/agencies/broking firms :
Name of insurance companies/agencies/broking firms Date Joined Date Left
3. Has any of your insurance company representation(s) ever been terminated or curtailed? *Yes/No
If ‘Yes’, please state the name of the insurance company(ies) and the date(s) of such termination
or curtailment.
(The question is not restricted to current application but includes all previous employment/involvement.)
4 Continuous Professional Development (CPD) Requirement :
Have you fulfilled the minimum number of hours of CPD training and such other requirements Yes/No
as may be determined by GIA in the previous year.
SECTION III
Honesty, Integrity & Reputation
I/We declare as follows :
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.
2. I/We have not been convicted of :
a) An offence under the Insurance Act (Chapter 142) or any regulations made thereunder;
b) An offence under the Penal Code (Chapter 224)
c) An offence under the Monetary Authority of Singapore Act (Chapter 186) or any regulations made
thereunder.
d) An offence under any Act or regulations administered by the Monetary Authority of Singapore
e) A criminal offence involving fraud, misrepresentation or dishonesty; or
f) An offence under any statute which is a re-enactment Act, repealing Act or a consolidation Act in respect of
any of the legislations referred to above.
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 government or regulatory body acting under any Act or subsidiary legislation
(hereinafter referred to as “any Regulator”)
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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
Businesses 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) its business or business licence has been suspended or revoked by the Monetary of Singapore or any
Regulator.
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 for Agents; and
c) The Singapore General Insurance Code of Practice
5. I am not an undischarged bankrupt or a person in respect of whom a bankruptcy proceeding is pending in Court.
6. I/We have not :
a) Entered into a composition or a scheme of arrangement with creditors; or
b) One or more outstanding judgements against me/us which has/have been unsatisfied within 7 days from the
date of the judgement.
7. 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 the declarations
herein contained untrue or incorrect.
Signature : Date :
SECTION IV (To be completed by the Principal for whose representation this application is made).
Principal Representation I
Name of Principal : ETIQA INSURANCE PTE. LTD.
Business Address : ONE RAFFLES QUAY #22-01 NORTH TOWER SINGAPORE 048583
Name of Applicant :
Type of Agency with the Applicant (Please put ‘X’ in the appropriate box)
[ ] Underwriting Agent [ ] Credit Agent [ ] Cash Agent
We hereby declare that (insert name of
applicant) to the best of our belief and knowledge, the information given herein by the Applicant are true and correct and
the ‘Minimum Requirements For General Insurance Agents’ as laid down by the GIA have been complied with.
Name of the Principal Officer/Date
