Department of Finance

INSURANCE COMMISSION
APPLICATION FOR INSURANCE AGENT'S LICENSE
(Under Chapter IV, Title I of the Insurance code)

To the Insurance Commissioner:

The undersigned hereby applies for a license under the provisions of Chapter IV, Title I of the Insurance Code, to act
as insurance/general agent of the THE INSULAR LIFE ASSURANCE CO., LTD in respect of the kind of insurance indicated
herein:

NON-LIFE LIFE VARIABLE LIFE ACCIDENT AND HEALTH

Others (specify) ____________________________

and for that purpose submits the following statements and information required herein.
N/A
(Agency name if any)

1. Name of Applicant: KUA JERVIN YAU

(Surname) (First Name) (Middle Name)

2. Agent Type: Ordinary Agent ( ) General Agent ( )

3. Home Address: 58-B N/A NICANOR ROXAS ST, STA MESA HEIGHTS, LOURDES, QUEZON CITY, METRO
MANILA 1114

Business Address: _______________________________________________________________

TIN: 272-79-9559 E-mail Address: [email protected]

Mobile Number: 639778428684

4. Birth Date: 10/17/1989 Birth Place: NCR

5. Citizenship: FILIPINO Gender: MALE Marital Status: MARRIED

6. If Married a) Maiden Name: ___________________________________________________

b) Spouse Name: SHAYNE KRISTEL GO NUBLA

7. If naturalized citizen of the Philippines, give date and place of naturalization and attach photocopy of certificate of
naturalization N/A

FOR IC USE ONLY

Verified by: ______________ Date: _______ Processed by: ______________ Date: ________

Approved by: ______________ Date: ________

License Fee: _____________ OR No.: ____________ Date _______ CA No.: _____________

REMARKS:
__________________________________________________________________
Application for Insurance Agent's License
Insurance Commission

8. If applicant is a foreigner, giver serial number, date and place of issue of alien certificate of registration (ACR) and the
immigrant certificate of residence (ICR) for the current year and attach photocopy of each thereof
N/A
9. If applicant is a partnership, association or corporation:
a) Attach a certified true copy of the certificate of registration, articles of partnership, association or incorporation
and by-laws.
b) State percentage of Filipino participation in the partnership, association or corporation: N/A

10. Any license previously granted to act as insurance/general agent in this country? State name of insurance company
represented: NO
NO INCOME
11. Have you filed your income tax return for the preceding year? NO If not, give reason:

12. In the blanks below, state your last (2) employers:

Inclusive Dates
From - To Name of Employer Where In What Capacity Reason For Leaving
NONE

13. Are you an official or an employee of an insurance company or broker? If yes, give the position held: NO

14. Are you a government employee? NO If yes, attach the necessary clearance/permission from the Head of the
Department or Agency in accordance with Section 18, of Memorandum Circular No. 15, series of 1999 of the Civil
Service Commission.

Executed this 6TH this day of MARCH 20 22 , at QUEZON CITY , Philippines.

Signature of Applicant

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Application for Insurance Agent's License
Insurance Commission

AFFIDAVIT OF VERIFICATION

Republic of the Philippines)

Province/City of ________ ) S.S.

I, KUA, JERVIN YAU , being duly sworn, depose and say that I am the person named in and
who signed the foregoing application; that I know the contents thereof and the statements made and answers to question
therein are true.

Affiant

TIN 272-79-9559
SSS No. 34-2648042-1

SUBSCRIBED AND SWORN TO before me this _____ day of __________ 20 _____ , Affiant/s exhibited
to me his/her ______________________________ issued on _____________________ 20 _____ , at
________________________________.

Notary Public
Doc. No. __________
Page No. __________
Book No. __________
Series of 20 __________ (Documentary Stamp Paste Here)

APPROVED AND COUNTERSIGNED for the THE INSULAR LIFE ASSURANCE CO., LTD for the solicitation or
procurement of application for life/non-life insurance.

Authorized Representative of the Company

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Application for Insurance Agent's License
Insurance Commission

CERTIFICATE OF WAIVER

WE HEREBY CERTIFY:

That we know the applicant KUA, JERVIN YAU , that a thorough investigation has been
made into his/her character, conduct and fitness; he/she is of good moral character and worthy of a Certificate of Authority
and that he/she has had experience in each of the kinds of insurance he/she proposes to write or solicit under the
Certificate of Authority applied for.
That we have communicated with the former and present employees of the applicant and the replies have been
satisfactory.
That to the best of our knowledge, information and belief, all statements and answers contained in the application
have been in the handwriting of the applicant respect to the questions applicable to him/her.
If and when the agency is terminated, written notice thereof will be given forthwith to the Insurance Commission
together with the reason thereof.
In consideration of the Certificate of Authority to be issued to the above-mentioned applicant, under the provision
of Section 299 of the Insurance Code, we hereby waive, on behalf of -

THE INSULAR LIFE ASSURANCE CO., LTD

the right to appeal to the Secretary of Finance in case of revocation of by the Insurance Commissioner of the certificate to
be issued in favor of the above-mentioned applicant and agree to cancel at once the contract of agency between said
applicant and the company upon receipt of the notice of revocation.

Executed in MUNTINLUPA on 03/06/2022 .

THE INSULAR LIFE ASSURANCE CO., LTD
TIN 320-000-464-124
By:
Authorized Representative of the Company

N.B. No person, partnership, association or corporation required by Law to file an income tax return shall be issued a
license to engage in any trade, business or corporation or practice a profession unless he shall have presented to the officer
issuing such license or permit proof that he has filed his income tax return during the preceding year and that income taxes
due have been paid thereon. For the purpose of this Act, a copy of such income tax return on which is shown a certification
or statement by the collector of Internal Revenue or his duly authorized representative that the aforesaid income tax
return, and the corresponding receipts showing payment of all income taxes due thereon, shall be sufficient proof.

Any person, partnership, association or corporation who obtains a license mentioned in the preceding paragraph without
presenting the aforementioned certification of the Collector of Internal Revenue or his duly authorized representative,
under the pretext that he or it is not required by law to file an income tax return when in truth he or it is so required, or
under any other misrepresentation, shall be liable to fine of not more than Five Hundred Pesos, or imprisonment of not
more than one year or both, in the discretion of the Court. In case of partnership, association, the manager or the
equivalent officer thereof shall be held responsible and in addition, the license shall be revoked. (Section 1, Republic Act
No. 1568).

IC-LLI-DP-002-F-01
Rev. 1