AG LIFE CHANGER FORM (AGENCY PARTNER)

Allianz Life Changer (AGENCY PARTNER)

Licensing Requirements
NEW APPPLICANT
DISCLAIMER:

KINDLY USE CAPITAL LETTER ONLY
LICENSE TYPE APPLYING*

LIFEVARIABLE LIFE
APPLICANT'S FULL NAME*

First NameMiddle NameLast NameSuffix
DATE OF BIRTH*

MonthDayYear
PLACE OF BIRTH (MUNICIPALITY/CITY)*
PERSONAL EMAIL ADDRESS*
CITIZENSHIP*
SEX/GENDER*
CIVIL STATUS*
If Married, kindly provide Maiden Name*
Spouse Complete Name*
IF NATURALIZED CITIZEN OF THE PHILIPPINES*
IF NATURALIZED, UPLOAD COPY OF CERTIFICATE OF NATURALIZATION

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IF APPLICANT IS A FOREIGNER*
UPLOAD IMMIGRANT CERTIFICATE OF RESIDENCE (ICR)

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UPLOAD ALIEN CERTIFICATE OF REGISTRATION(ACR)

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IF APPLICANT IS PARTNERSHIP, ASSOCIATION OR CORPORATION (A)*
IF APPLICANT IS PARTNERSHIP, ASSOCIATION OR CORPORATION (B)*
HAVE YOU FILED YOUR ITR FOR THE PRECEEDING YEAR*
IF NOT FILED ITR, PLEASE PROVIDE REASON.*
ARE YOU AN OFFICIAL OR EMPLOYEE OF INSURANCE COMPANY OR BROKER*
IF YOU ARE EMPLOYEE OR BROKER, KINDLY PROVIDE POSITION HELD*
ARE YOU A GOVERNMENT EMPLOYEE*
IF YES, upload clearance/permission from the head of the department/agency

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HOME ADDRESS*

House number and street

Barangay and subdivision

City/MunicipalityState / Province

Postal / Zip Code
MOBILE NUMBER*
Please enter a valid phone number (09xxxxxxxxx)
Position Applying For*
Recruiter's Name *

First NameLast Name
Recruiter's Code*
Put N/A if no issued code
Agency Leader's Name*

First NameLast Name
Agency Leader's Code*
Put N/A if no issued code
Agency Leader Email Address*
example@example.com
MP Email Address*
example@example.com
Agency Name*
Emergency Contact Person*
Emergency Contact Number*
Please enter a valid phone number (09xxxxxxxxx)
Are you a Senior Citizen Applicant*
Tax Identification Number*
Use this format 000-000-000
SSS Number*
Indicate your SSS Number using this format 00-0000000-0 and not UMID number (10 digits only).
Proof of TIN*

Upload any proof of your TIN - 1901, 1701, BIR ID, ITR, etc
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Proof of SSS*

Upload any proof of your SSS number - SSS ID, E-1 etc (UMID is not accepted by IC)
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Highest Educational Attainment*
Where did you hear from us?*
Do you have any Life, Non-Life Insurance, Pre-need and/or HMO Experience?*
Most recent Non-Life Insurance, Pre-need and/or HMO Company:*
Put N/A if none
Upload Clearance Certificate from previous Non-Life Insurance, Pre-need and/or HMO Company:

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PREVIOUS LIFE INSURANCE AFFILIATION (PUT N/A IF NOT APPLICABLE)*

	COMPANY	LICENSE TYPE	LICENSE NO.	YEAR ISSUED/RENEWED
PREVIOUS INSURANCE 1
PREVIOUS INSURANCE 2

EMPLOYMENT DETAILS/ LAST 2 EMPLOYERS (PUT N/A IF NOT APPLICABLE)*

	NAME AND ADDRESS OF EMPLOYER	POSITION	EMPLOYMENT DATE (FROM and TO)	REASON FOR LEAVING
EMPLOYER 1
EMPLOYER 2

Have you made any political contribution or charitable donation as a way of influencing official action?*
Are you related to or have a close relationship with a government official?*
Have you ever been accused, investigated/arrested, indicted or convicted breaching Anti-Bribery or Anti-Corruption law?*
Have you ever been accused, investigated/arrested, indicted or convicted of any criminal or civil case?*
Have you ever declared bankruptcy and/or have you ever been declared bankrupt by regulators/authorities?*
Have you ever been investigated for any administrative case?*
Have you ever been terminated or forced to resign from any employment or affiliates of any Life, Non-Life, Pre-need, HMO or other Financial Institution?*
I hereby authorize Allianz PNB Life Inc:

1. To use and process, whether manually or via electronic channels, any and all information I have provided above, including Personal and Sensitive
Personal Information, to facilitate, monitor, and improve matters pursuant to my application.

2. To share, transfer, and/or disclose the said information
to any of its intermediaries, subsidiaries, affiliates, service providers, partners, and government agencies for the said purposes.

3. I likewise promise to inform Allianz PNB Life Insurance, Inc. of any change relating to my personal information.

4. I further understand and acknowledge that such Personal Information may be used by AZPNBL to comply with its legal or regulatory obligations under applicable local or foreign laws, rules and regulations relating to matters including but not limited to anti-money laundering and tax monitoring/review/reporting.

5. I further understand and acknowledge that upon signing this Jotform application, it will automatically reflect such signature with date stamp to all documents.
That I hereby authorize Allianz PNB Life, Inc.to do the following as stated above:*

YESNO
I declare that all information supplied above and all other records and documents submitted by me in support of this application are true and correct to the best of my knowledge and belief. I agree that any false record on information supplied may result in rejection of this application or if already accepted, termination of my contract. I agree that a photographic copy of this authorization and waiver shall be valid as the original.*

YESNO
Applicant's Signature:*

Clear
DATE SIGNED:*

MonthDayYear
Date
Hour MinutesAM/PM Option

DOWNLOADABLE FORMS

You may download the forms below
Affidavit of Non-Filing (Downloadable Form)
Group Life Insurance Form (Downloadable)

Information Security and Data Privacy and Undertaking

I, {applicantsFull}, a licensed agent of Allianz PNB Life Insurance, Inc. (the “Company”) understand and accept the following terms and conditions:

1. I understand that the Company will provide me with Digital tools (Digital Tools) including but not limited to Allianz Journey and an email address, designed to facilitate ease of solicitation or procurement of applications of insurance and servicing the needs of my clients.

2. I agree to use my own device, with the approval of the Company, to access the Digital Tools. I shall register my device with the Company’s IT Department and will inform the Company in the event of loss, change of ownership, and other relevant updates.

3. I acknowledge that while the Digital Tools will be installed or used in my own device, ownership of the Digital Tools and all information contained therein shall remain solely with the Company and my continued access to the Digital Tools shall be at the sole discretion of the Company.

4. I understand that as an agent of the Company and as a user of the Digital Tools, I will have access to Allianz proprietary information and Allianz customer personal information (collectively “Information”). As such, I undertake to:

a. Treat the Information with utmost confidentiality and to use it solely for official Allianz PNB purposes.

b. Complete all training and awareness programs addressing Information security, data privacy, and confidentiality as mandated by the Company.

c. To report all phishing and spam attempts by forwarding the suspicious email to spam@allianz.com

d. Comply with applicable Company guidelines, relevant regulations on information security and data privacy, particularly Republic Act No. 10173 or the Philippine Data Privacy Act of 2021.

e. Report to protectprivacy@allianzpnblife.ph and dsu@allianzpnblife.ph immediately but no later than 12 hours from my reasonable belief that the Digital Tools or any Information contained therein may be compromised.

f. I will give my full cooperation in any investigation or assessment of a potential or actual data breach.
I hereby certify that I will faithfully comply with the aforesaid guidelines set by the Company and any violation of the above-mentioned conditions may be a ground for disciplinary action and even termination of my contract with the Company.

I AGREE

Submit / Upload your Requirements here

Kindly submit all your accomplished form and requirements below
INSURANCE COMMISSION LICENSING REQUIREMENTS
Notarized AIAL Form*

Upload your Notarized AIAL here *
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Copy of Exam Result*

Please upload your exam result here: Life Result *Variable Result *
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2x2 Picture (with white background)*

Upload your scanned 2X2 PROFESSIONAL ID Picture (white background)
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ALLIANZ LICENSING REQUIREMENTS
Training Certificate (BOSS 3)*

Please upload your Certificate of BOSS 3 here *
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2 Government Valid ID (with 3 specimen signature)*

Upload your Government ID here *
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Group Life Insurance Form

Upload your Accomplished Group Life Insurance here *
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Copy of Clearance (from previous employer) even not insurance related*

Upload your scanned copy of Clearance *
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Proof of License Fee/s Payment:*

See below instruction and details
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LICENSE FEE AMOUNT AND ACCOUNT DETAILS

LICENSE FEE PER LICENSE TYPE: 1,515.00
BANK - PNB
ACCOUNT NAME - Allianz PNB life Insurance Inc
ACCOUNT NUMBER - 1111-7000-6478

SEE BELOW INSTRUCTION IF YOU WILL USE GCASH

Please be informed that for all Gcash payment, we will only accept the email notification for License fees and Exam fees as advice from Accounting Team.

This is due to the changes of the Bank SOA ( per email below) that Gcash payment can be validated on invoice number only and not instapay trace number anymore. To aware delays of processing/ validation of payment for a certain transaction, please be guided.

Sample of email notification.

ACCEPTED:

NOT ACCEPTED:
ITR or Affidavit of Non-Filing*

ITR or Affidavit of Non-Filing (tax) – (this is based on the question no. 11 in AIL form) a. ITR – if you filed your income tax return for previous year b. Notarized Affidavit of Non-filing – if you did not file your income tax return for previous year, kindly submit affidavit of non filling (please see downloadable template above)*
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By clicking the "SUBMIT" button below, I hereby authorized ALLIANZ PNB LIFE to process all the information provided herein, including but not limited to sharing of the same to its parent company, subsidiaries and affiliates including third party (e.g. vendors or subcontrators) for the processing of the agreed licensing application before the Insurance Commission and/or bank purposes; whenever necessary, for the fulfillment of any party's contractual obligations. I also authorize ALLIANZ PNB LIFE, its parent company, subsidiaries and affiliates and third parties, to store the data herein and use the same for data analytics. I also agree to receive notices and announcements from ALLIANZ PNB LIFE, its parent company, subsidiaries and affiliates and third parties, via E-mail, telephone calls or any other available mode of communications as they may deem proper.
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Allianz Life Changer (AGENCY PARTNER)

NEW APPPLICANT

DISCLAIMER:

DOWNLOADABLE FORMS

Submit / Upload your Requirements here

INSURANCE COMMISSION LICENSING REQUIREMENTS

ALLIANZ LICENSING REQUIREMENTS