Gunakan Form ini untuk transfer servicing dari agent asal ke agent baru

1. 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 Date
Code No.
Note: Only in-force policies are allowed to transfer
Seven (7) policies and above required RDM/SRDM’s recommendation
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For Transfer of Servicing and commission (Applicable under same agency only)
I (existing agent) ____________________________________________ hereby agree to transfer servicing and commission to the above-
named agent.
___________________________ __________________________
Signature of Agent Endorsed by QL
Code No: Name:
Code No.
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RDM/SRDM’s recommendation for transfer for seven (7) policies and above
Justification: ________________________________________________________________________________________
__________________________
RDM/SRDM
Name:
Region
Appendix 1 : Transfer of Servicing Form

2. 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 agent’s 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: __________________ Approved By: __________________
Name: Name:
Date: Date:
Note: Please refer to the next page