Year 2008 - Insurance Industry after current finanical tsunami

Membership No. Assigned Company Nominee 1 Nominee 2 Nominee 3 Nominee 4 Nominee 5 Membership Appl ication Form(A) F U L L M E M B E R / C O R P O R A T E A S S O C I A T E M E M B E R Please complete and mail this form together with your payment to: Director of Membership Extension, GPO Box 6542, Hong Kong. Website : www.hkcii.org Type of Membership Applied (Please refer to the membership definition stated below before completion) □ Full Member □ Corporate Associate Member } Entrance Fee: HK$1,000; Annual Subscription: HK$750 ( Please tick as appropriate.) Section 1 - Company Information Name of Company : Number of Employees: Company Address : Tel : Fax : E-mail : Business Registration No. : Year Established : □ We are registered agent / authorised broker in compliance with the law of Hong Kong. □ We are business organisation closely related to Insurance industry. □ Main line of business: General / Life / Composite Insurance / others: Please enclose a copy of your Business Registration Document with this application for our records. ( Please tick as appropriate.) Section 2 - Name of Nominee(s) Eachmember is entitled tofive Individual membership including one appointed nominee. All correspondence will be forwarded to appointed nominee 1* (Entrance Fee: HK$200; Annual Subscription: HK$150) 1 Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : 2 Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : 3 Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : 4 Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : 5 Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : We, the undersigned hereby apply to become Full Member / Corporate Associate Member of the Hong Kong Chamber of Insurance Intermediaries and agree to comply with all the regulations as set by the Chamber from time to time. We understand that the acceptance of our application is subject to the final approval of the Executive Committee of the Chamber. Our membership fee made payable to Hong Kong Chamber of Insurance Intermediaries is herewith enclosed as follows : Bank name : Cheque number : Amount (HK$) : Signature of applicant (With company chop where appropriate) Proposer : Name : Date : Note: “ Full Member ” - is an organisation who carries on business in Hong Kong as an insurance intermediary under a valid business registration certificate issued by Hong Kong S.A.R.Government and is to be represented by a Nominee of such organisation registeredwith the Chamber and duly accepted by the Chamber. (A“Nominee”is an Individual Member of the Chamber who is the chief or a very senior executive officer of, and nominated by a Full Member.) Total membership fee for Full Member: HK$2,100.00. “ Corporate Associate Member ” - is an organisation whose business activities are closely related to the insurance industry and duly accepted by the Chamber. Please tick this box if you do not want your personal details to be made available to the public. For office use only Date received : Date ack. sent : Date approved : Date cert. sent : Membership due date : Remarks :