FORM APPLICATION NEW AGENT

Basic Information

Recruiter

Agency Level *

1
Personal Information - Identity

Enter Identity (According to e-KTP)

Gender *

Last Education *

2
Personal Information - Domicile

Identity Address *

If the address domicile matches the ID card

Mailing Address / Domicile

3
Personal Information - Contact

Enter Celluler Number, Home Phone & Email

4
Personal Information - Spouse

Select Marital Status & Enter number of Dependent Children

Marital Status *
5
Personal Information - Financial

Enter Financial Information

Has the Candidate ever been declared bankrupt?

6
Job Data - Agency

Enter Agency information

Has the Candidate ever been registered as a Life Insurance Agent?

Is the Candidate`s Husband/Wife an Agent or Agency Manager at PT. Hanwha Life Insurance Indonesia?

7
Job Data - Relation

Relationship with Hanwha Marketing Staff

8
Personal Information - Emergency Contact

Enter Relative / Family Name

Has the candidate ever been involved in any criminal cases?

9
Statement

1. All data, information, and statements that I provide in this Application Form are true, complete and in accordance with the actual situation. If it is found that the data, information and statements that I provide in this Application Form are not true, then PT Hanwha Life Insurance Indonesia (“Company”) has the right to unilaterally terminate/cancel the Agency Agreement without providing any compensation to me.

2. I understand that (i) if I do not have an AAJI Agency License in the name of the company no later than 3 (three) months after I sign this New Agent Application Form or (ii) I do not pass the interview process with SH/RH/ND/Head of Agency, then my Agent code will be automatically cancelled and the e-Recruitment process will be terminated without any prior notification to me.

3. In the event that I have become a Company Marketer, I am willing to submit to and be bound by the Agency Agreement, Agency Code of Ethics and other provisions governing insurance marketers, both issued by the Company and by authorized agencies.

4. I sign this Application Form consciously and without coercion from any party whatsoever.

Agree *
10
Signature
Agent *
11
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