Application Checklist (HK) - v2014APR
FORM NAME
VERSION
REMARKS
General Documents (Essential)
Application Form (not included)
2014/01
[G48 for PCF] & [G25 for TAS] & [G08C/E for PHS]
Illustration (not included)
201401
Included G42 (Broker Version) & IFSAD (For PCF only)
CTC by Consultant with Company Chop
ID & Address Proof Copy (not included)
(G43) Insurance Needs Analysis Form
⒏
諸
亖
2013/11
(G01) Consultant’s Report
2014/01
(G65) Applicant’s Authorization: Commission Disclosure
2013/04
(G03) Amendment to Application (if applicable)
2014/01
Payment Documents (Essential)
(G04) Payment Slip
2010/05
(G02) Credit Card Payment Authorization
2006/05
Applicable for Initial Premium ONLY
(Q23) Non Hong Kong Resident’s Declaration
2012/03
For Non-HK Residents
(G39) Insurance Consultant's Declaration in Respect of PRC Resident's Insurance Application
2008/01
For PRC Residents only
(Q25) Supplementary Personal Statement for Insurance Application
2005/05
For PRC Residents only
(F01) Confidential Consultant’s Report – Client’s Background
2009/03
Necessary for Annual Premium > HKD$500K
(F02) Financial Statement of the Proposed Insured / Payor
2012/04
Necessary for Annual Premium > HKD$1M
(G58) Request for Making Advance Payment of Target Yearly Premium of Basic Plan
2011/11
For PCF/TAS Prepayment ONLY
(G31) Personal Statement of Proposed Insured Proposed Policy Owner
2014/01
Necessary for adding Riders to Basic Plan
Non-HK residents / PRC Documents (Optional)
Download from system if necessary
Please use Double-Side Printing for the attachment. And forms would be updated from time to time.
Extra Forms may require for some cases, please check the New Business Administrative Manual before the application.
This application checklist is just for reference only.
First Policy No.
รԫٝঅ໢ᒳᇆ;
Second Policy No.:
รԲٝঅ໢ᒳᇆΚ
INSURANCE CONSULTANT'S DECLARATION IN RESPECT OF PRC RESIDENT'S
INSURANCE APPLICATION (G39) խഏփ‫ދاࡺچ‬অհঅᙠ᥽ംᜢࣔ
Name of First Insurance Consultant:
รԫ‫ټ‬অᙠ᥽ംࡩ‫ټ‬Κ
First Insurance Consultant's Code:
Name of Second Insurance Consultant:
รԲ‫ټ‬অᙠ᥽ംࡩ‫ټ‬Κ
Second Insurance Consultant Code:
รԲ‫ټ‬অᙠ᥽ംᒳᇆΚ
รԫ‫ټ‬অᙠ᥽ംᒳᇆΚ
Name of Proposed Insured:
Name of Proposed Policy Owner:
ᄷ࠹অԳࡩ‫ټ‬Κ
ᄷঅ໢਍‫ڶ‬Գࡩ‫ټ‬Κ
IЯWe declare that:
1.
The entire solicitation process leading to the signing of the application for the above numbered insurance policy was
conducted by meЯus in Hong Kong.
2.
IЯWe have complied with the rules and regulations of the People’s Republic of China in relation to the sale and Яor
promoting of insurance products to PRC residents.
3.
IЯWe have not promoted andЯor sold, in any manner, any insurance product of MassMutual Asia Ltd. (“the Company”)
in Mainland China.
4.
IЯWe have not exhibited or distributed any of the Company’s marketing materials andЯor selling tools (including
application forms, sales proposals, sales brochures andЯor sales software, etc.) in Mainland China.
5.
IЯWe have not taken any action (including the distribution of myЯour business cards, etc.) which may be regarded as
promoting or selling insurance in Mainland China.
6.
In compliance with the Code of Practice for the Administration of Insurance Agents adopted by the Company, IЯwe as
insurance agent(s) hasЯhave not paid or offered to pay to the Proposed Policy Owner, Proposed Insured, Referrer or any
other person or institute, any rebate of premium, commission or other incentive not specified in the insurance policy
(including, but not limited to, payment or partial payment, of accommodation or travel expenses for visiting Hong Kong).
Insurance Consultant’s Declaration:
IЯWe understand that:
1.
It is an offence under the laws of the People’s Republic of China for anyone not authorized by the Chinese Government to
promote or sell any insurance in Mainland China.
2.
If IЯwe commit the above offence, myЯour insurance agent’s license in Hong Kong may be revoked.
অᙠ᥽ംᜢࣔʳ ˍʳ
‫ء‬Գʻ࿛ʼᜢࣔˍʳ
༉Ղ૪অ໢հ‫ع‬ᓮऱᖞଡሏᎅመ࿓݁‫ءط‬Գʻ࿛ʼ‫ڇ‬ଉཽၞ۩Ζ
‫ء‬Գʻ࿛ʼբᙅ‫ښ‬խဎԳ‫ا‬٥ࡉഏ‫ڶ‬ᣂංᐖ֗ᔭഇঅᙠข঴࿯խഏփ‫اࡺچ‬ऱऄࠏ֗๵ࡳΖ
‫ء‬Գʻ࿛ʼ޲‫אڶ‬ٚ۶‫࣍ڤݮ‬խഏփ‫چ‬ංᐖ֗Яࢨᔭഇભഏᆄຏঅᙠࠅ੊‫ૻڶ‬ֆ‫׹‬ʻψ‫ء‬ֆ‫׹‬ωʼհข঴Ζ
‫ء‬Գʻ࿛ʼ޲‫ڇڶ‬խഏփ‫چ‬Δ୶‫ࢨق‬੔࿇ٚ۶᥆࣍‫ء‬ֆ‫׹‬ข঴ऱᇷற֗ᛜᔭՠࠠʻ‫ץ‬ਔ‫ع‬ᓮ।Εૠቤ஼Εข঴១տ֗Я
ࢨᔭഇຌٙ࿛ʼΖ
‫ء‬Գʻ࿛ʼࠀ޲‫࣍ڶ‬խഏփ‫܂چ‬ٚ۶‫ױ‬౨๯ᎁ੡ᔭഇঅᙠհ۩੡ʻ‫ץ‬ਔ੔࿇‫ء‬Գʻ࿛ʼհ‫ׂټ‬࿛ʼΖ
ᙅᅃ‫ء‬ֆ‫ࢬ׹‬ආ‫ش‬ऱঅᙠ‫ז‬෻ጥ෻‫ښ‬ঞΔ‫ء‬Գ ࿛ ‫܂‬੡অᙠխտԳΔࠀ޲‫ٻڶ‬ᄷঅ໢਍‫ڶ‬ԳΕᄷ࠹অԳΕ᠏տԳ
ࢨࠡ‫ה‬Գ‫ࢨד‬ᖲዌ༼ࠎࢨ࿠ᚨ༼ࠎٚ۶অ၄‫܁ڃ‬Ε‫܁‬८ࢨࠡ‫ڇה‬অ໢փ޲‫ڶ‬ਐࡳऱᚌ༡ʻ‫ץ‬ਔΔ‫܀‬լૻ֭࣍‫ב‬ຝٝ
ࢨ٤ᑇࠩଉཽհଇമࢨٌຏ၄‫ش‬࿛ʼΖʳ
ʳ
‫ء‬Գʻ࿛ʼࣔ‫ˍػ‬ʳ
ٚ۶Գ‫آד‬ᆖ‫ڶ‬ᣂຝ॰඄ᦞۖ‫ڇ‬խഏփ‫چ‬ᔭഇঅᙠΔ‫ܛ‬ᤛ‫ح‬խဎԳ‫ا‬٥ࡉഏհऄࠏΖ
‫ءڕ‬Գʻ࿛ʼᤛ‫ح‬Ղ૪ऄࠏΔ‫ء‬Գʻ࿛ʼ‫ڇ‬ଉཽհঅᙠխտԳྨᅃ‫ױ‬౨ᄎ๯‫ٶ‬ᔭΖ
ʳ
1.
2.
3.
4.
5.
6.
(
)
1.
2.
รԫ‫ټ‬অᙠ᥽ം᡽ᆟ;
ֲཚΚ
รԲ‫ټ‬অᙠ᥽ം᡽ᆟ;
Date:
Signature of Second Insurance Consultant:
Я
G39-01
MassMutual Asia Ltd.
छ୽࿲೽߳ᓎ‫ࢸٳ‬Ԥ३ϴѧ
Я Я ִЯֲЯ‫ڣ‬α
Date:
Signature of First Insurance Consultant:
Hong Kong Head Office - 12/F, MassMutual Tower, 38 Gloucester Road, Wanchai, Hong Kong
Macau Branch Office - Avenida Praia Grande No.517, Edificio Comercial Nam Tung, 16-E2, Macau
MM
DD
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ֲཚ!;! Я Я )ִЯֲЯ‫*ڣ‬
MM
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2008 - P.1 of 1
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ᖾ॰։ֆ‫׹‬Κᖾ॰ত᨜Օ್ሁ628ᇆতຏ೸ᄐՕლ27ᑔF3ஆ Tel ሽᇩΚ (853) 2832 2622
Fax
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