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APPLICATION FORM: EXEMPTIONUNDER REGULATION 6.5 OF THE REGULATIONS MADE UNDER THE LONG-TERM INSURANCE ACT, 1998 AND SHORT-TERM INSURANCE ACT, 1998
Note:
The application form must be completed with reference to the applicable Legal and Policy Framework that appears at the end of the application form.
Insurer Name
Insurer Number
Type of notification (please indicate with “x” for all the questions in the spaces provided below):
Application under the -
Long-term Insurance ActShort-term Insurance Act
Application for exemption from -
Regulation 6.2(2)Regulation 6.2(3)
[refer to part 2][refer to part 3]
Non-mandated intermediary (binderholder) / Mandated IntermediaryName:
FAIS registration No:
Contact details:
Registered address
Telephone number
Facsimile number
Mobile number
Is the party a subsidiary of the insurer (Yes / No)?
If not a subsidiary, but otherwise associated, please describe how it is associated to the insurer.
Underwriting manager (binderholder) / Subsidiary / associate of the binderholder
Name:
FAIS registration No:
Contact details:
Registered address
Telephone number
Facsimile number
Mobile number
Is the party a subsidiary or associate of the insurer?
If an associate, please describe how it is associated to the insurer.
3.1In respect of what is the relaxation of the capital adequacy requirement applied for?
Motivate why the insurer is of the view that noconflict of interest or potential conflict of interest exists between the binder holder and the associate of that binder holder with whom the binder holder wants to do business.
5.1Is there any other information or documentation that is relevant to this application?
YESNO
5.2If the answer to 5.2 is yes, list the information or documents in Part 6.
Clearly indicate the attachments that have been included with this application form.
Description / Number of pagesAttachment A / A statement by the Board of Directors of the insurer that it supports the application and that no conflict of interest or potential conflict of interest exists between the insurer and its subsidiary or associate binder holders.
Attachment B / A diagram explaining the relationship / associationbetween the insurer, the binderholder and associate with whom the latter wants to do business
Attachment C
Attachment D
Explanatory Note:
Details of the public officer must be provided. The Registrar will liaise with the public officer and all correspondence from the Registrar will be sent to the public officer.
7.1Full name and surname
7.2Telephone / cellular number
7.3Fax number
7.4E-mail address
The insurer hereby authorises the Financial Services Board, and its duly authorised agent, to request or confirm any information provided in support of this application with any person.
The insurer authorisessuch other personto furnish information regarding this application to the Financial Services Board and its duly authorised agent. The insurer unconditionally indemnifies the Financial Services Board, its agent and any person/s against any liability that may result from furnishing information in this regard.
I, …………………………………………………………………..[Insert full name of public officer], identity / passport number ……………………………… hereby certify, to the best of my knowledge, that the information provided in the application form and any attached information are complete, accurate, true and not misleading in any respect.
………………………………..
Signature of public officer Date
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LEGAL AND POLICY FRAMEWORK
EXEMPTIONUNDER REGULATION 6.5 OF THE REGULATIONSMADE UNDER THE LONG-TERM INSURANCE ACT, 1998 AND SHORT-TERM INSURANCE ACT, 1998
- INTRODUCTION
This application form relates to an application for approval by the Registrar for exemptionunder regulation 6.5 of the Regulations made under the Long-term Insurance Act (LTI Act), 1998 and Short-term Insurance Act, 1998(STI Act).
Regulation 6.5 provides thatdespite regulation 6.2(2) or (3), the Registrar may on application by an insurer that is the holding company or associate of more than one person referred to in regulation 6.2(2) or (3), exempt that insurer and non-mandated intermediary, underwriting manager that is a subsidiary or associate of that insurer from regulation 6.2(2) or (3), if the Registrar is satisfied that no conflict of interest or potential conflict of interest exists.
An insurer wishing to apply for the exemption from regulation 6.2(2) or (3) must complete this application form and submit the supporting documentation called for in this application form.
B.INTERPRETATION
In this form any word or expression defined in the LTI Act or STI Act or Part 6 of the Regulations made under the LTI Act and STI Act, as the case may be, including any measure referred to in the definitions of the LTI Act or STI Act in sections 1(1) of the LTI Act or STI Act, have, unless the context otherwise indicates, the meaning so defined.
Note that, if there is any discrepancy between this application form and the provisions of the LTI Act and STI Act, the provisions in the LTI Act and STI Act will be deemed correct.
C.INSTRUCTIONS
1.Applications must be submitted directly to the Registrar of Long-term and Short-term Insurance at the Financial Services Board.
2.This application form must be completed in full by the responsible person and be signed by the public officer or the person duly authorised to sign this form. If a person other than the public officer of the insurer signs the form, proof of the authorisation must be attached to this application form.
3.The format of the form or the wording of questions may not be changed. All questions must be answered and if not applicable marked “N/A”.
4.The application must be accompanied by the documents referred to and listed in paragraph D below and all items of supporting documentation that are listed and identified in part 6 of the application form.
5.The application must be submitted in sufficient time before the approval is needed so as to allow the Registrar time to consider the application and seek information or clarification, where necessary.
6.Application forms that do not comply with 1 – 6above will not be processed and will be returned to the applicant.
D.DOCUMENTS THAT MUST ACCOMPANY THIS APPLICATION
The application must be accompanied by at least the following documents and listed in Part 6 of the application form:
- A statement by the Board of Directors of the insurer that it supports the application and that no conflict of interest or potential conflict of interest exists between the insurer and its subsidiary or associate binder holders.
- A diagram explaining the relationship / association between the insurer, the binder holder and associate with whom the latter wants to do business.
E.ADDITIONAL INFORMATION
The Registrar, in accordance with section 4(2) of the STI Act may request additional information relating to this application.