Annual Registration Renewal Form – General Insurance Mediation Business
Please answer the questions below in accordance with your class of General Insurance Mediation Business (“GIMB”) registration. Where answers require further details, please provide these in the area provided before submitting to the Jersey Financial Services Commission (the “Commission”).
PART A
To be answered by all registered General Insurance Mediation Businesses
Please state your GIMB reference number: / GIMB
Failure to submit this form and the accompanying fee on or before 31 January shall result in the registered person being subject to a late payment fee in accordance with the General Insurance Mediation Business Fees notice (the “Fees Notice”) that is available on the Commission’sWebsite.
1. / Confirm the Class of General Insurance Mediation Business that relates to your registration.P / Q / R / S
If the class of business that you have selected above is different from that previously approved by theCommission, please provide the reason for this on a separate sheet.
2. / Please confirm whether you wish to continue your registration under the Financial Services (Jersey) Law 1998? / YES / NO
If NO, please provide details below stating why registration is no longer required before completing the Declaration and returning to the Commission.
3. / Do you handle insurance money, as defined in Article 3 of the Financial Services (General Insurance Mediation Business (Client Assets))(Jersey) Order 2005? / YES / NO
If YES, and you hold a Class R or S registration, please ensure that you answer question 10 under Part C of this annual registration renewal form.
4. / Has there been any significant change to the information that was supplied to the Commission at application or last renewal? / YES / NO
If YES, provide comprehensive details and, where necessary, submit supporting documentation(e.g. - ownership, structure, principal persons, sources of business, financing arrangements etc.).
5. / Has there been any change to the panel of insurers or other intermediaries used by the registered person since the application or the last renewal? / YES / NO
If YES, please provide a comprehensive list of all of the insurers or other intermediaries that have been added or removed from your panel(to include the full name and address).
In questions 6 and 7 below, the annual renewal of registration fees are payable in accordance with Schedule2 to the General Insurance Mediation Business fees notice that is published on the Commission’s Website:
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Annual Registration Renewal Form – General Insurance Mediation Business
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Annual Registration Renewal Form – General Insurance Mediation Business
6. / Is the registered person entitled to the reduced annual registration renewal fee in Table 2 of Schedule 2 to the General Insurance Mediation Business Fees notice? / YES / NO7. / State the fee amountenclosed with this registration renewal. / AMOUNT
PART B
To be answered by all registered General Insurance Mediation Businesses with Class P, Q and R Registrations
Jersey-based registered person
Worldwide brokerage income / Non-Jersey-based registered person
Jersey brokerage income only
AMOUNT / AMOUNT
If brokerage income is nil, please state the reason for this below.
NUMBER
9. / Please state the number of customers represented by this brokerage amount?
PART C
To be answered by all registered General Insurance Mediation Businesses with Class P and Q Registrations
(Question 10 to be answered by registered persons that answered YES to question 3 in part A of this annual registration renewal form.)
11. / Is any general insurance mediationbusiness introduced to you by appointed representatives, sub agents, introducers or similar persons? / YES / NO
If YES, please provide comprehensive details for each business introducer associated with the registered person’s business in or from within Jersey to include the full name and address of each business and confirm whether they are appropriately regulated to introduce such business.
12. / Please confirm whether the registered person has been granted a formal exemption from the Financial Services (General Insurance Mediation Business (Accounts, Audits, Reports and Solvency)) (Jersey) Order 2005 (the“Accounts Order”). / YES / NO
If YES and the registered person’s home regulator is NOT the Commission, please provide a copy of the most recent home regulator return to include the solvency calculation (e.g. in the UK, the “RMAR” return) and go toquestion 14.
If NO, please answer questions 13 and 14.
13. / Have you complied with the required margins of solvency in accordance with the provisions of Part 3 of the Accounts Order? / YES / NO
If YES, provide a copy of the most recent solvency calculations together with thecorresponding supporting documentation (annotated to the amounts in each row of the calculations).
If NO, please state the details (to include the when and how) the registered personadvised the Commission of non-compliance with the provisions of Article 15 of the Accounts Order.
14. / Please confirm the registered person’s most recent financial year-end. / DATE (DD/MM/YYYY)
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Annual Registration Renewal Form – General Insurance Mediation Business
DECLARATION
We confirm that all changes in principal person(s), as defined in Article1 of the Financial Services (Jersey) Law 1998 (the “Law”), have been notified to the Commission.
We authorise the Commission to make such enquiries and to seek such further information, as it thinks appropriate, to verify the information contained in this form.
We declare, on behalf of the registered person, that the information supplied in this form and on all supporting attachments is complete, true and accurate to the best of our knowledge and belief. We are aware that it is an offence under Article 28 of the Law to knowingly or recklessly provide any information that is false or misleading.
Signed by persons named below who are duly authorised on behalf of the registered person.
Signatory 1 / Signatory 2Name of Signatory:
Position of Signatory:
Signature:
Date: / // / //
Please provide an appropriate contact name and telephone number in the event that someone from the Commission may need to contact you in respect of your annual registration.
Contact Name:
/ Contact Number:(Direct line)
On completion, please return this form to the Commission at the address shown below, together with the registration fee and any supporting documentation:
Jersey Financial Services Commission
PO Box 267
14-18 Castle Street
St. Helier
JERSEY
JE4 8TP
Data Protection (Jersey) Law 2005 (“Data Protection Law”)Personal data provided in this form will be used by the Commission – a data controller as defined in the Data Protection Law – to discharge its statutory functions under the Financial Services (Jersey) Law 1998, as amended, and it may be disclosed to third parties for those purposes. Further information may be found in the Commission’s data protection policy, copies of which are available on request from the Commission and which may also be found on
Checklist please ensure that you have supplied the following in addition to this annual registration renewal form:
Registration fee (Please identify the payment method used); and / Cheque / Bacs
Any additional information/attachments (e.g. Questions 2, 4, 5, 11 and 13):
Latest home regulatory return (e.g. RMAR), as applicable
Latest solvency calculations and supporting documentation, as applicable
Note:Registered persons may settle their registration renewal fee either by Cheque, made payable to “Jersey Financial Services Commission”, or by electronic transfer.
The Commission’s bank details are as follows:
Name:Jersey Financial Services Commission
Branch Identifier:MIDLGB22
Bank Sort Code:40-25-34
Account Number:01483455
Iban reference:GB35MIDL40253401483455
Please ensure the following information is incorporated into the narrative accompanying payment:
- Name of the registered person;
- GIMB reference; and
- Reason for payment (i.e. registration renewal).
If you wish to be advised of receipt, we would recommend that you select a confirmation option when you set up the remittance on your e-banking. We also recommend you to keep a note of the value date (i.e. not the instruction date)in the event of an enquiry on the registered person’s electronic remittance.
For Official Use OnlyFee Received / Date Received
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