APPLICATION FOR CHANGE OF SERVICING AGENT FORM

Please send the form through Internet Correspondence Module (ICM) for better monitoring and update.
Alternatively, please send to Agency Support Department / your respective Agency Director.

I hereby request to transfer the policy-(ies) listed below to the new servicing agent of my choice.

AGENT NAME AGENT CODE

NO LIFE ASSURED NAME POLICY NUMBER

1.

2.

3.

4.

5.

DECLARATION

Policyholder
I hereby confirm that I am making this request on my own free will without the prior interference of any party.

Policyholder NRIC No.

Signature | Name Date

New Servicing Agent

I hereby confirm and agree to accept the transfer of the policy-(ies) listed above and shall render my service
to the policyholder. I understand that the Company reserves the right to take action deemed necessary
against me upon any breach of the Company’s Agency Rules & Regulations.

New Servicing Agent IAC No.

Signature | Name Date

IMPORTANT NOTE: Only applicable to policy still in-force and agent has “active” status in the company’s
record.
(The process for a change of servicing agent may require up to 21 working days and you will be notified of
the outcome of your request).

ASD-COAForm-V1-032022

Great Eastern Life Assurance (Malaysia) Berhad (93745-A)

Head Office Menara Great Eastern 303 Jalan Ampang, 50450 Kuala Lumpur
Tel: 603 4259 8888 Fax: 603 4259 8000