Insurance and Financial Practitioners Association of Singapore Member of APFinSA MediShield Life Project 2015 Insurance and Financial Practitioners Association of Singapore Volunteer’s Declaration Form In view of your participation as a volunteer in the MediShield Life Project 2015, please check the corresponding box under the respective column (if you’re an agent or a manager/director) to confirm that you have or have not met the specified criteria. For Agent Criteria Yes No For Manager / Director Yes No Full time adviser & minimum of 12 months in the industry N.A Has sold at least 6 shield plans in the last 12 months (Oct 2013-Sep 2014) N.A $12,000 First Year Commission in the last 12 months (Oct 2013-Sep 2014) or at least $36,000 income based in life business in the financial year 2013 N.A Persistency Ratio – 80%: 19-month persistency (Regular Premium) N.A No misconduct or warning letter from company and/or regulators, no pending court case (Free from compliance/disciplinary actions from company) Must be an IFPAS member For non members, please complete this form Must be Singaporean or Permanent Resident (PR) in Singapore I hereby confirm and verify that the disclosures made above are complete and correct. I agree to commit and attend all briefing and training sessions with respect to the MediShield Life Project 2015. I will adhere and comply with all requirements pertaining to this project at all times. ____________________ ______________________ __________ Name & Signature of Agent Designation: RNF No: Contact No: Email add: Company: Name & Signature of Immediate Supervisor Designation: RNF No: Contact No: Email add: Organisational Stamp (if any) Important Notes 1. 2. Please send us back the declaration form via fax at 6534 2345 or email at [email protected] To receive more updates, join our Facebook group ‘Friends of IFPAS’ 35 Selegie Road #10-01 Parklane Shopping Mall Singapore 188307 T (65) 6535 1221 F (65) 6534 2345 E [email protected] W www.ifpas.org.sg