SHAHREZAL BIN IBNRAHIM

TRANSNATIONAL INSURANCE BROKERS (M) SDN BHD

INSURANCE INTRODUCER PROFILEGeneral Instructions:

1. This form is to be completed and signed by the introducer or authorised personnel of a corporate introducer.

2. All sections must be completed, insert Not Applicable or Nil where appropriate.

A.BACKGROUND

For Corporate Introducer

Name of Company

: Company Registration No.: Mailing Address

:

Income Tax File No.

:

Telephone No. : .. Fax No. H/P No.

Email Address :

Contact Person (s)

: 1) ..2)

Designation (s)

: 1) .2)

Nature of Companys Business: .

Type of Company (please tick the below box)

Sole Proprietor Partnership Private Limited Other (specify)

NAMES OF SHAREHOLDERSNAME OF DIRECTORS

1.1.

2.2.

3.3.

4.4.

5.5.

6.6.

For Individual Introducer

Name of Person

:

I.C No.

:

Mailing Address

:

Postcode : ..

Income Tax File No.

:

Telephone No. : Fax No. . H/P No.

Email Address : .

Occupation

: Name of Employer : Name of Spouse : Occupation

: .Name of Employer : ...................................B.RELATIONSHIP WITH CLIENTS TO BE INTRODUCED

NO.QUESTIONSYES NO

1Does your Company/you or your immediate family members have a controlling interest in the clients to be introduced?

2Are you or any of your immediate family members employed or is a director of any of the clients to be introduced?

3Are you or any of your immediate family members and servants employed by or is a director of Transnational Insurance Brokers (M) Sdn Bhd?

4Are you aware if any of the employees/directors of Transnational Insurance Broker (M) Sdn Bhd have a controlling interest in a corporate introducer?

* Note : Immediate family members include employees/directors spouses, children and parents

C.LIST OF CLIENTS TO BE INTRODUCEDNO.NAME OF CLIENTS

1

2

3

4

5

I/We hereby declare that to the best of my/our knowledge and belief, the above particulars and information contained in this form is true and correct and that no other material facts have been misstated, suppressed or omitted. If any of the above particulars and information is subsequently found to be untrue, the Company has the right to nullify the Insurance Introducer Agreement signed with me/us.

Signature: .

Date

:

Name

: ..

Designation:

Company Stamp:

FOR OFFICIAL USEIntroduced By

:

(Signature & Name)

(Date)

VERIFIER TO COMPLETENO.QUESTIONSYES NO

1Have we obtained complete information & documentation ?

2Have I met the introducer?Please state the date of the meeting _________________

3Have we ascertain that the introducer is necessary in securing the business?

Verified By

:

(Signature & Name) (Date)

Approved By

:

Chief Executive Officer (Signature & Name)

(Date)

TRANSNATIONAL INSURANCE BROKERS (M) SDN BHD

Name of Insurance Introducer: ____________________________________________

LIST OF CLIENTS INTRODUCED

(Please note that the list below comprises clients secured with the assistance of the Insurance Introducer and maybe updated from time to time.)

NO.NAME OF CLIENTDATE SECUREDDATE TERMINATED

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Recommended Introducer Fees Percentage (%): ___

Maximum : 30%

Reason for the appointment of introducer:

Comments:

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