Social Media Bancassurance Form

Full Name*

First NameMiddle NameLast NameSuffix

Nickname*

For COMPANY ID

Date of birth*

Address*

Street Address and Barangay

Street Address Line 2

CityProvince

Country

Email Address*

example@example.com

Mobile Number*

Please enter a valid phone number (11 digits)

Position Applying For*

Financial AdvisorSales ManagerRegional Business ManagerOther

Region*

Branch Assignment*

Where did you hear from us?*

Do you have any Sales or Financial Experience for 6 months to 1 year?*

YesNo

Most recent Life Insurance Company:*

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 investigated for any administrative case? *

Have you ever declared bankruptcy and/or have you ever been declared bankrupt by regulators/authorities? *

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 Insurance 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 as defined in the Philippine Data Privacy Act of 2012, to facilitate, monitor, and improve services related to my application and onboarding as well as any necessary acts of administration while I am affiliated with Allianz PNB Life Insurance, Inc. as its intermediary/distributor;

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 Allianz PNB Life Insurance, Inc. 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 agree that the collected information will be deleted in Jotform upon completion of my licensing requirements. Otherwise, it will be deleted after three (3) months if I have not submitted the complete requirements.

That I hereby authorize Allianz PNB Life Insurance, Inc. to process my personal information for application/onboarding-purposes and acts of administration while I am affiliated with Allianz PNB Life Insurance, Inc. as an intermediary/distributor:*

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 declare that the indicated recruiter and/or Agency Leader or Managing Partner is true and correct. • I declare that I have filled out the form once only. If there are changes in my answer, I will contact Distribution Licensing at distribution.licensing@allianzpnblife.ph. • 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

Allianz Life Changer