Year 2011 - Bancassurance – my perspective 銀行保險 我知我見

Membership No. Assigned Company Nominee 1 Nominee 2 Nominee 3 Nominee 4 Nominee 5 FULL MEMBER / CORPORATE ASSOCIATE MEMBER Tel: 8108 1238 Fax: 8108 1282 GPO Box 6542, Hong Kong Email: admin@hkcii.org 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$250; Annual Subscription: HK$600 ( 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) 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$) : 850 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 registered with 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.) “ Corporate Associate Member ” - is an organisation whose business activities are closely related to the insurance industry and duly accepted by the Chamber. For office use only Date received : Date ack. sent : Date approved : Date cert. sent : Membership due date : Remarks : Membership Application Form(A) * Each member is entitled to nominate its staff for individual membership including one appointed nominee*. All correspondence will be forwarded to appointed nominee 1*