Insurance Law INSURANCE (FORMS) REGULATIONS

CAYMAN ISLANDS Insurance Law INSURANCE (FORMS) REGULATIONS (2003 Revision) Supplement No. 4 published with Gazette No. 16 of 11th August, 2003. PUBLISHING DETAILS Revised under the authority of the Law Revision Law (1999 Revision). The Insurance (Forms) Regulations, 1980 made the 10th day of June, 1980 Consolidated with the - Insurance (Forms) (Amendment) (Licence Applications) Regulations, 2001 made the 12th day of April, 2001. And as amended by the - Cayman Islands (Constitution) (Amendment) Order 2003 (U.K.S.I. 2003 No. 1515) made the 12th day of June, 2003. Consolidated and revised this 8th day of July, 2003. Page 2 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations Arrangement of Regulations CAYMAN ISLANDS Insurance Law INSURANCE (FORMS) REGULATIONS (2003 Revision) Arrangement of Regulations Regulation Page 1. Citation ......................................................................................................................................5 2. Forms of application for licences ................................................................................................5 3. Forms of licenses.......................................................................................................................5 4. Certificate of compliance ............................................................................................................5 5. Financial statement ....................................................................................................................5 FIRST SCHEDULE 7 APPLICATION FOR A CLASS “A” INSURER’S LICENCE 7 APPLICATION FOR A CLASS “B” INSURER’S LICENCE 11 APPLICATION FOR AN INSURANCE AGENT’S LICENCE 14 APPLICATION FOR AN INSURANCE BROKER’S LICENCE 17 APPLICATION FOR AN INSURANCE SUB-AGENT’S LICENCE 20 APPLICATION FOR AN UNDERWRITING MANAGER’S LICENCE 21 SECOND SCHEDULE 24 LICENCE 24 THIRD SCHEDULE 25 CERTIFICATE OF COMPLIANCE FOR ALL CLASSES OF INSURERS LICENCES, OTHER THAN LICENCES FOR APPROVED 25 FOURTH SCHEDULE 27 ANNUAL FINANCIAL STATEMENT FOR YEAR ENDING 20 . 27 c Revised as at 8th day of July, 2003 Page 3 Insurance (Forms) Regulations Regulation 1 CAYMAN ISLANDS Insurance Law INSURANCE (FORMS) REGULATIONS (2003 Revision) 1. Citation 1. These regulations may be cited as the Insurance (Forms) Regulations (2003 Revision). 2. Forms of application for licences 2. The forms set out in the First Schedule hereto shall be employed for the respective purposes of the Law and of these regulations specified in the heading to each of such forms. 3. Forms of licenses 3. Licences shall be in the form set out in the Second Schedule hereto. 4. Certificate of compliance 4. A certificate of compliance furnished under section 7(3) shall be in the form set out in the Third Schedule hereto and each licensed Insurer other than an approved external insurer shall furnish such a certificate in relation to its insurance business during each financial year within six months of the last day of the year. 5. Financial statement 5. The financial statement under section 7(5) shall be in the form set out in the Fourth Schedule hereto. c Revised as at 8th day of July, 2003 Page 5 Regulation 5 Insurance (Forms) Regulations Page 6 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FIRST SCHEDULE FIRST SCHEDULE (regulation 2) FORM 1 CAYMAN ISLANDS FIRST SCHEDULE INSURANCE LAW (2003 Revision) INSURANCE (FORMS) REGULATIONS (2003 Revision) APPLICATION FOR A CLASS “A” INSURER’S LICENCE (Section 4 (2)) Please complete all sections as fully as possible, giving reasons for non- compliance if any, and attaching appendices where appropriate. Note: An applicant seeking a Class ‘A’ Licence under section 4(7) as an approved external insurer need complete paragraph 1-12 only. 1. Name of applicant……………………………………………………………. 2. Date on which applicant commenced, or intends to commence, carrying on business in or from within the Islands ……………………………………………………………………………… 3. Whether business being, or proposed to be, transacted is “general” or “long term” or both (as defined in section 2) ……………………………………………………………………………… 4. Address of (a) principal office …………………………………………………………… (b) registered office …………………………………………………………… (c) head office in the islands …………………………………………………………… 5. Name of manager or head of office in the Islands ……………………………………………………………………………….. c Revised as at 8th day of July, 2003 Page 7 FIRST SCHEDULE Insurance (Forms) Regulations 6. If the applicant is to depend upon agent or service companies for the provision of underwriting, management, financial or accounting services, please give details of such companies, including evidence of their agreement to provide the services mentioned. 7. Name of person resident in the Islands who is authorised to accept service of process in legal proceedings and notices on behalf of the applicant and who is approved or proposed for approval under section 7(2) ……………………………………………………………………………….. 8. (a) Branch applicants must provide written confirmation that their head office accepts full responsibility for all policies and contracts issued by the branch and also for all acts, omissions and liabilities of the branch. (b) Where the applicant is a subsidiary company state whether the parent company will provide a guarantee in respect of all policies or contracts issued by the branch and also for all acts omissions and liabilities of the subsidiary. 9. In respect of general domestic business state the applicant’s policy regarding availability of funds for prompt settlement of normal claims ……………………………………………………………………………… ……………………………………………………………………………… …………………………………………………………………………… 10. In respect of long term domestic business state the applicant’s policy regarding investment of consequent annual premium income in the Islands ……………………………………………………………………………….. ……………………………………………………………………………….. ………………………………………………………………………………. 11. List all insurance agents and insurance brokers, if any, who have or who are to have, the applicant’s underwriting authority to accept domestic business on its behalf ……………………………………………………………………………….. ………………………………………………………………………………. ……………………………………………………………………………… 12. To be completed only by an applicant seeking to be licensed as an approved external insurer A Attach (i) latest annual report and audited accounts; or (ii) statutory financial statement Page 8 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FIRST SCHEDULE B Attach (i) latest certificate of solvency; or (ii) certificate of compliance with insurance legislation in country of constitution, together with written confirmation that the certificate attached embraces all liabilities in respect of domestic business 13. Attach a copy of the act, charter, certificate of incorporation and memorandum of association and articles of association or other instrument of constitution of the applicant, as may be appropriate, verified by a statutory declaration made by a director, secretary or partner and duly authenticated as follows - (a) in the case of a company incorporated in the Islands, certified in accordance with the section 27 of the Companies Law (2003 Revision); (b) in the case of a foreign company certified and authenticated under public seal of the country, city or place under the laws of which such company has been incorporated; or (c) or in the case of companies not yet incorporated, the proposed documentation. 14. List all names (including any previous names), addresses and nationalities of all shareholders. In those instances where shares are held by a corporate body or bodies, the chain of connection to the ultimate owner must be shown. 15. Attach the annual accounts, for the two years preceding the year of application, of each shareholder which is a body corporate holding more than ten per cent of the applicant’s issued share capital or total voting rights, together with similar accounts for the parent body, if any, of each such body corporate. 16. Attach curricula vitae of all directors, managers and officers, including any previous names, and with particular emphasis on experience in the insurance profession. 17. Attach not less than three references acceptable to the Authority, including one character reference for, and one reference verifying the good financial standing of- (a) each director, manager and officer of the applicant; and (b) each shareholder and each beneficial shareholder who is a natural person holding more than ten percent of the applicant’s issued share capital or total voting rights, and, for each such director, manager, officer or shareholder, a police or other certificate satisfactory to the Authority that such director, manager, officer or shareholder has not been convicted of a serious crime or any offence involving dishonesty. 18. c Revised as at 8th day of July, 2003 Page 9 FIRST SCHEDULE Insurance (Forms) Regulations (a) Name and address of the principal agent or representative resident in the Islands …………………………………………………………………… …………………………………………………………………… (b) Address of designated principal office in the Islands where full business records will be kept …………………………………………………………………… 19. Name, address and professional qualification of auditors (and the country whose generally accepted accounting principles are to apply) and, if the application includes long term business, similar details of the actuary who will give required statutory certificates. Attach evidence that said auditors and actuary have agreed to accept appointment Auditor Actuary 20. (a) (For an existing insurer). Attach annual accounts for the three years preceding the date of this application. (b) (For an applicant for a new insurer’s licence). Attach a written undertaking to provide at least the minimum net worth requirements set out in section 4(9), together with a statement as to how said net worth is to be calculated. 21. Attach a business plan. The Authority may indicate that any part of the information included in the business plan shall not form part of this application for the purpose of sections 4(3) and 7(2). 22. Have any of the parties connected with this application ever applied, either individually or in conjunction with others, for authority to transact insurance in any other jurisdiction? If so please give details. Application is accordingly hereby made for the licence specified above and it is certified that all the particulars contained in this Application and in the documents accompanying it or otherwise furnished in support hereof are true and correct. Dated this day of , 20 . ……………………………………………………………………... [Name of applicant] by its *Director/*Secretary/* or other person duly authorised. Signed:…………………………………………………………….. WITNESS: Name: Occupation: Address: *Delete words which are not applicable Page 10 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FIRST SCHEDULE FORM 2 CAYMAN ISLANDS INSURANCE LAW (2003 Revision) INSURANCE (FORMS) REGULATIONS (2003 Revision) APPLICATION FOR A CLASS “B” INSURER’S LICENCE (Section 4(2)) Please complete all sections as fully as possible, giving reasons for non- compliance if any, and attaching appendices where appropriate. 1. Name of applicant…………………………………………………………… 2. Whether licence applied for is Restricted or Unrestricted. 3. Date on which applicant commenced, or intends to commence, carrying on business in or from within the Islands. ……………………………………………………………………………… 4. Whether business being, or proposed to be, transacted is “general” or “long term” or both (as defined in section 2). ………………………………………………………………………………... 5. Address of - (a) principal office ………………………………………………………………. (b) registered office ………………………………………………………………. 6. If the applicant is to depend upon agent or service Companies for the provision of underwriting, management, financial or accounting services, please give details of such companies including evidence of their agreement to provide the services mentioned. 7. Attach evidence of the proper incorporation of the applicant pursuant to section 5 of the Companies Law (2003 Revision), and a copy of the memorandum of association and articles of association, or other instrument of constitution of the applicant, as may be appropriate or, in the case of companies not yet incorporated, the proposed documentation. 8. List all names (including any previous names), addresses and nationalities of all shareholders. In those instances where shares are held by a corporate body or bodies the chain of connection to the ultimate owner must be shown. c Revised as at 8th day of July, 2003 Page 11 FIRST SCHEDULE Insurance (Forms) Regulations 9. Attach the annual accounts, for the two years preceding the year of application, of each shareholder which is a body corporate holding more than ten per cent of the applicant’s issued share capital or total voting rights, together with similar accounts for the parent body, if any, of each such body corporate. 10. Attach curricula vitae of all directors, managers, and officers, including any previous names, and with particular emphasis on experience in the insurance profession. 11. Attach not less than three references acceptable to the Authority, including one character reference for and one reference verifying the good financial standing of- (a) each director, manager and officer of the applicant; and (b) each shareholder and each beneficial shareholder who is a natural person holding more than ten per cent of the applicant’s issued share capital or total voting rights, and, for each such director, manager, officer or shareholder, a police or other certificate satisfactory to the Authority that such director, manager, officer or shareholder has not been convicted of a serious crime or any offence involving dishonesty. 12. (a) Name and address of the principal agent or representative resident in the Cayman Islands …………………………………………………………………… …………………………………………………………………… (b) Address of designated principal office in the Islands where full business records will be kept …………………………………………………………………… 13. Name, address and professional qualification of auditors and the country whose generally accepted accounting principles are to apply. Attach evidence that said auditors have agreed to accept appointment 14. Name and address of person resident in the Islands who is authorised to accept service of process in legal proceedings and notices on behalf of the applicant and who is approved or proposed for approval under section 7(2). ………………………………………………………………………………... ……………………………………………………………………………….. 15. (a) (For an existing insurer). Attach annual accounts for three years preceding the date of this application. Page 12 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FIRST SCHEDULE (b) (For an applicant for a new unrestricted class “B” insurer’s licence).Attach a written undertaking to provide at least the minimum net worth requirements set out in section 4(8), together with a statement as to how said net worth is to be calculated. 16. Attach a business plan. The Authority may indicate that any part of the information included in the business plan shall not form part of this application for the purpose of sections 4(3) and 7(2). 17. Have any of the parties connected with this application ever applied, either individually or in conjunction with others, for authority to transact insurance business in any other jurisdiction? If so please give details. Application is accordingly hereby made for the licence specified above and it is certified that all the particulars contained in this application and in the documents accompanying it or otherwise furnished is support hereof are true or correct. Dated this day of , 20 . ………………………………………………………….. [Name of applicant] by its *Director/*Secretary/* or other person duly authorised. Signed:…………………………………………………………… WITNESS: Name: Occupation: Address: *Delete words which are not applicable c Revised as at 8th day of July, 2003 Page 13 FIRST SCHEDULE Insurance (Forms) Regulations FORM 3 CAYMAN ISLANDS INSURANCE LAW (2003 Revision) INSURANCE (FORMS) REGULATIONS (2003 Revision) APPLICATION FOR AN INSURANCE AGENT’S LICENCE (Section 4(2)) Please complete all sections as fully as possible, giving reasons for non- compliance if any, and attaching appendices where appropriate. 1. Name of applicant…………………………………………………………… 2. Date on which applicant commenced, or proposes to commence, carrying on business in or from within the Islands, and with which principal company. ………………………………………………………………………………... 3. Address of main or registered office in the Islands. ………………………………………………………………………………... 4. If incorporated- (a) Attach evidence of proper incorporation under section 5 of the Companies Law (2003 Revision) and a copy of the memorandum of association and articles of association or other instrument of constitution of the applicant as may be appropriate or, if not yet incorporated, the proposed documentation. (b) List all names (including any previous names), addresses and nationalities of all share holders. In those instances where shares are held by a corporate body or bodies the chain of connection to the ultimate owner must be shown. (c) Attach curricula vitae of all directors, managers and officers. 5. Attach the annual accounts, for the two years preceding the year of application, of each shareholder which is a body corporate holding more than ten per cent of the applicant’s issued share capital or total voting rights, together with similar accounts for the parent body, if any, of each such body corporate. 6. If not incorporated, names, addresses, nationalities and curricula vitae of the applicant and any person acting as a manager, or other officer or partner, as the case may be. Page 14 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FIRST SCHEDULE 7. If incorporated, attach not less than three references acceptable to the Authority, including one character reference for and one reference verifying the good financial standing of - (a) each director, manager and officer of the applicant; and (b) each shareholder and each beneficial shareholder who is a natural person holding more than ten per cent of the applicant’s issued share capital or total voting rights, and, for each such director, manager, officer or shareholder, a police or other certificate satisfactory to the Authority that such director, manager, officer or shareholder has not been convicted of a serious crime or any offence involving dishonesty. 8. If not incorporated, attach not less than three references acceptable to the Authority, including one character reference for, and one reference verifying the good financial standing of, the applicant and any person acting as a manager, or other officer or partner, as the case may be; and for each such person, a police or other certificate satisfactory to the Authority that the person has not been convicted of a serious crime or any offence involving dishonesty. 9. Attach evidence of the existence of a power of attorney, agency agreement or guarantee, or of professional indemnity insurance as required under section 8(3). 10. Attach a list of all sub-agents authorised by the applicant to solicit domestic business on his behalf, and of all insurance agents associated with the applicant company. 11. Have any of the parties connected with this application ever applied, either individually or in conjunction with others, for authority to transact insurance business in any other jurisdiction? If so, please give details. Application is accordingly hereby made for the Licence specified above, and it is certified that all the particulars contained in this application and in the documents accompanying it or otherwise furnished in support hereof are true and correct. Dated this day of , 20 . ……………………………………………………………………. [Name of Applicant] Signature of applicant, if an individual ……………………………………………………………………… WITNESS: Name: Occupation: Address: OR by its *Director/*Secretary/ or *other person duly authorised c Revised as at 8th day of July, 2003 Page 15 FIRST SCHEDULE Insurance (Forms) Regulations Signed…………………………………………………………………… WITNESS: Name: Occupation: Address: *Delete words which are not applicable In the case of personal Life Agents the application should be witnessed by the principal officer of the general agents in the Islands with whom the applicant is or will be associated. Page 16 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FIRST SCHEDULE FORM 4 CAYMAN ISLANDS INSURANCE LAW (2003 Revision) INSURANCE (FORMS) REGULATIONS (2003 Revision) APPLICATION FOR AN INSURANCE BROKER’S LICENCE (Section 4 (2) ) Please complete all sections as fully as possible, giving reasons for non- compliance if any, and attaching appendices where appropriate. 1. Name of Applicant…………………………………………………………… 2. Date on which applicant commenced, or proposes to commence carrying on business in or from within the Islands ………………………………………………………………………………... 3. Address of principal or registered office ……………………………………………………………………………….. 4. If incorporated - (a) Attach evidence of proper incorporation under section 5 of the Companies Law (2003 Revision) and a copy of the memorandum of association and articles of association or other instrument of constitution of the applicant as may be appropriate; or if not yet incorporated, the proposed documentation. (b) List all names (including any previous names), addresses and nationalities of all shareholders. In those instances where shares are held by a corporate body or bodies the chain of connection to the ultimate owner must be shown. (c) Attach curricula vitae of all directors, managers and officers. 5. Attach the annual accounts, for the two years preceding the year of application, of each shareholder which is a body corporate holding more than ten per cent of the applicant’s issued share capital or total voting rights, together with similar accounts for the parent body, if any, of each such body corporate. 6. If not incorporated, names, addresses, nationalities and curricula vitae of the applicant and any person acting as a manager, or other officer or partner, as the case may be. c Revised as at 8th day of July, 2003 Page 17 FIRST SCHEDULE Insurance (Forms) Regulations 7. If incorporated, attach not less than three references acceptable to the Authority, including one character reference for and one reference verifying the good financial standing of - (a) each director, manager and officer of the applicant; and (b) each shareholder and each beneficial shareholder who is a natural person holding more than ten per cent of the applicant’s issued share capital or total voting rights, and, for each such director, manager, officer or shareholder, a police or other certificate satisfactory to the Authority that the person has not been convicted of a serious crime or any offence involving dishonesty. 8. If not incorporated, attach not less than three references acceptable to the Authority, including one character reference for, and one reference verifying the good financial standing of, the applicant and any person acting as a manager, or other officer or partner, as the case may be; and for each such person, a police or other certificate satisfactory to the Authority that the person has not been convicted of a serious crime or any offence involving dishonesty. 9. Attach evidence of the existence of professional indemnity insurance as required under section 9(2). 10. Attach a list of all sub-agents authorised by the applicant to solicit domestic business on his behalf, and of all Insurance agents that may be associated with the applicant. 11. Attach a list of all insurers with whom the applicant has entered into any form of agency agreement. 12. Attach a business plan. 13. Have any of the parties connected with this application ever applied, either individually or in conjunction with others, for authority to transact insurance business in any other jurisdiction? If so, please give details. Application is accordingly hereby made for the licence specified above and it is certified that all the particulars contained in this application and in the documents accompanying it or otherwise furnished in support hereof are true and correct. Dated this day of , 20 . …………………………………………………………………….. [Name of Applicant] Signature of applicant, if an individual ……………………………………………………………………… WITNESS: Name: Occupation: Address: Page 18 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FIRST SCHEDULE OR by its *Director/*Secretary/ *or other person duly authorised Signed…………………………………………………………………… WITNESS: Name: Occupation: Address: *Delete words which are not applicable c Revised as at 8th day of July, 2003 Page 19 FIRST SCHEDULE Insurance (Forms) Regulations FORM 5 CAYMAN ISLANDS INSURANCE LAW (2003 Revision) INSURANCE (FORMS) REGULATIONS (2003 Revision) APPLICATION FOR AN INSURANCE SUB-AGENT’S LICENCE (Section 4(2)) Please complete all sections as fully as possible, giving reasons for non- compliance if any, and attaching appendices where appropriate. 1. Name and address of applicant……………………………………………… 2. Date on which applicant commenced, or proposes to commence, carrying on business in or from within the Islands. 3. Attach not less than three references acceptable to the Authority, including one character reference for, and one reference verifying the good financial standing of, the applicant. 4. Attach a police or other certificate satisfactory to the Authority that the applicant has not been convicted of a serious crime or any offence involving dishonesty. 5. Details of the applicant’s experience in the business of insurance. 6. Have any of the parties connected with this application ever applied, either individually or in conjunction with others, for authority to transact insurance business in any other jurisdiction? If so, please give details. Application is accordingly hereby made for the Licence specified above and it is certified that all the particulars contained in this application and in the documents accompanying it or otherwise furnished in support hereof are true and correct. Dated this day of , 20 . ……………………………………………………………………. Signature of Applicant WITNESS: Name: Occupation: Address: Page 20 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FIRST SCHEDULE FORM 6 CAYMAN ISLANDS INSURANCE LAW (2003 Revision) INSURANCE (FORMS) REGULATIONS (2003 Revision) APPLICATION FOR AN UNDERWRITING MANAGER’S LICENCE (Section 4 (2) ) Please complete all sections as fully as possible, giving reasons for non- compliance if any, and attaching appendices where appropriate. 1. Name of Applicant…………………………………………………………… 2. Date on which applicant commenced, or proposes to commence carrying on business in or from within the Islands, and with which principal company. ………………………………………………………………………………... 3. Address of main or registered office in the Islands ……………………………………………………………………………….. 4. If incorporated- (a) Attach evidence of proper incorporation pursuant to section 5 of the Companies Law (2003 Revision) and a copy of the memorandum of association and articles of association or other instrument of constitution of the applicant as may be appropriate; or if not yet incorporated, the proposed documentation. (b) List all names (including any previous names), addresses and nationalities of all shareholders. In those instances where shares are held by a corporate body or bodies the chain of connection to the ultimate owner must be shown. (c) Attach curricula vitae of all directors, managers and officers. 5. Attach the annual accounts, for the two years preceding the year of application, of each shareholder which is a body corporate holding more than ten per cent of the applicant’s issued share capital or total voting rights, together with similar accounts for the parent body, if any, of each such body corporate. 6. If not incorporated, names, addresses, nationalities and curricula vitae of the applicant and any person acting as a manager, or other officer or partner, as the case may be. c Revised as at 8th day of July, 2003 Page 21 FIRST SCHEDULE Insurance (Forms) Regulations 7. If incorporated, attach not less than three references acceptable to the Authority, including one character reference for and one reference verifying the good financial standing of - (a) each director, manager and officer of the applicant; and (b) each shareholder and each beneficial shareholder who is a natural person holding more than ten per cent of the applicant’s issued share capital or total voting rights, and, for each such director, manager, officer or shareholder, a police or other certificate satisfactory to the Authority that the person has not been convicted of a serious crime or any offence involving dishonesty. 8. If not incorporated, attach not less than three references acceptable to the Authority, including one character reference for, and one reference verifying the good financial standing of, the applicant and any person acting as a manager, or other officer or partner, as the case may be; and for each such person, a police or other certificate satisfactory to the Authority that the person has not been convicted of a serious crime or any offence involving dishonesty. 9. Attach a list of all insurers for whom the applicant is, or will be engaged to act as manager or consultant. 10. Attach a business plan. 11. Have any of the parties connected with this application ever applied, either individually or in conjunction with others, for authority to transact insurance business in any other jurisdiction? If so, please give details. Application is accordingly hereby made for the licence specified above and it is certified that all the particulars contained in this application and in the documents accompanying it or otherwise furnished in support hereof are true and correct. Dated this day of , 20 . …………………………………………………………………….. [Name of Applicant] Signature of applicant if an individual ……………………………………………………………………… WITNESS: Name: Occupation: Address: OR by its *Director/*Secretary/ *or other person duly authorised Signed…………………………………………………………………… WITNESS: Name: Occupation: Page 22 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FIRST SCHEDULE Address: *Delete words which are not applicable c Revised as at 8th day of July, 2003 Page 23 SECOND SCHEDULE Insurance (Forms) Regulations SECOND SCHEDULE INSURANCE LAW (2003 Revision) regulation 4 INSURANCE (FORMS) REGULATIONS (2003 Revision) LICENCE NO.................. ……………………………………………………………………………............……….. is hereby licensed under the Insurance Law (2003 Revision), to carry on business in or from within the Cayman Islands as ……………………………………………under section…………………… of the Law , subject to the provisions of the said Law and, in particular, to the condition that the Licensee shall forthwith notify the Governor of any change in the information supplied in the application for this Licence. Given this day of , 20 at George Town on the Island of Grand Cayman. …………………………………………………………………... Governor in Cabinet Page 24 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations THIRD SCHEDULE THIRD SCHEDULE regulation 5 CAYMAN ISLANDS INSURANCE LAW (2003 Revision) INSURANCE (FORMS) REGULATIONS (2003 Revision) CERTIFICATE OF COMPLIANCE FOR ALL CLASSES OF INSURERS LICENCES, OTHER THAN LICENCES FOR APPROVED EXTERNAL INSURERS (Section 7 (3)) I/We……………………………………………………………………………….. [Name] of…………………………………………………………………………………... [Full business address] DO HEREBY CERTIFY as follows- 1. That I/we am/are- *(a) the duly appointed independent auditor(s) or (b) the underwriting manager of …………………………………………………………………………………….. [Name of Licensed Insurer] Which is the holder of a currently valid ……………………………………………………………………..Licence No. [Category of Licence] under the abovementioned Law. 2. That, to the best of our knowledge and belief and subject to the exceptions or qualifications, if any, mentioned below, the said licence holder has during the period____________________to ______________________________ carried on its insurance business in accordance with the information provided in its licence application, subject to changes approved by the Governor. This certificate relates only to the following of such information:- (a) The classes of insurance business conducted by the licence holder. c Revised as at 8th day of July, 2003 Page 25 THIRD SCHEDULE Insurance (Forms) Regulations (b) The particulars described in the application, in the case of Class ‘A’ insurers at paragraphs 4 to 7, 11, 13, 14, 18 and 19 and in the case of Class ‘B’ insurers at paragraphs 5 to 8 and 12 to 14. (c) The Business Plan (excluding information which the Authority has indicated does not form part of the application for purposes of sections 4 (3) and 7 (2). EXCEPTIONS OR QUALIFICATIONS Dated at this day of , 20 . ..…………………………………………………………………… [Signature of person[s] furnishing this Certificate] Name and position of individual signing above certificate. *Delete if inappropriate. Page 26 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FOURTH SCHEDULE FOURTH SCHEDULE regulation 6 CAYMAN ISLANDS INSURANCE LAW (2003 Revision) INSURANCE (FORMS) REGULATIONS (2003 Revision) ANNUAL FINANCIAL STATEMENT FOR YEAR ENDING 20 . (section 7 (5)) Licence No. Name of Company: Part A Please attach directors report [if any], and audited financial statement in the normal published form. Part B Balance Sheet Current year Previous year 1. Investment assets (per Part C) 2. Real estate held for own use 3. Other fixed assets 4. Investment income receivable 5. Cash at bank (non invested) 6. Premiums receivable 7. Other assets ______________ ________________ ______________ ________________ 8. Unearned premiums 9. Reinsurance premium payable 10. Other liabilities c Revised as at 8th day of July, 2003 Page 27 FOURTH SCHEDULE Insurance (Forms) Regulations Current year Previous year 11. Insurance funds- 11.1 General business (per part E) 11.2 Long term business ______________ ________________ ______________ ________________ Shareholders equity- 12.1 Share capital 12.2 Retained earnings (per part D) 12.3 Other (describe) ______________ ________________ ______________ ________________ Part C Investment Assets Current year Previous year Total Invested Total Invested within Cayman within Cayman Islands Islands 1. Fixed deposits with banks and financial institutions. 2. Government and Government guaranteed issues- 2.1 Treasury bills 2.2 Bonds 2.3 Other (describe) 3. Quoted Investments- 3.1 Bonds and commercial paper 3.2 Ordinary shares 3.3 Preference shares 3.4 Other (describe) 4. Unquoted Investments- 4.1 Bonds and commercial paper Page 28 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FOURTH SCHEDULE 4.2 Ordinary shares 4.3 Preference shares 4.4 Other (describe) 5. Loans- 5.1 To policy holders 5.2 Mortgages on real estate 5.3 Secured other than on real estate 5.4 Unsecured 5.5 Other (describe) 6. Real Estate- 6.1 Undeveloped land 6.2 Rented property 6.3 Other (describe) 7. Other (describe) Note (a) The above amounts should be stated net of provisions for permanent diminution in value and net of provision for losses. (b) Please supply details of market and/or net realisable values of each category of assets if less than the above stated carrying values. (c) Give details of any charges or encumbrances on the above assets. (d) Related party assets should be separately disclosed. c Revised as at 8th day of July, 2003 Page 29 FOURTH SCHEDULE Insurance (Forms) Regulations Part D Statement of Income and Retained Earnings Current year Previous year 1. Transfer from (to) revenue accounts- 1.1 General business account (per Part E) 1.2 Long term business account 2. Investment income not allocated to revenue accounts. 3. Administration and general expenses not allocated to revenue accounts ( ) ( ) 4. Other items (describe) _________ __________ 5. Net income 6. Retained earnings at beginning of year. 7. Appropriations from (to) share-holders reserves (describe) 8. Dividends paid ( ) ( ) _________ __________ 9. Retained earnings at end of year _________ __________ Part E General business revenue account Current year Previous year Total Cayman Total Cayman Is. domestic Is. domestic business business 1. Fund brought forward at beginning of year- 1.1 Reserve for outstanding reported losses Page 30 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FOURTH SCHEDULE 1.2 Reserve for losses incurred but not reported. 1.3 Other (describe) _________ _________ _________ Sub-total _________ _________ _________ 2. Earned Premiums- 2.1 Unearned premium brought forward 2.2 Premiums written (net of refunds and rebates) 2.3 Unearned premiums carried forward Sub-total _________ _________ _________ 3. Investment income 4. Other items (describe) 5. Transfer from statement of income and retained earnings _________ _________ _________ 6. Total of items 1 to 5 7. Claims paid including costs of settlement 8. Commission and underwriting expenses 9. Administration and general expenses 10. Other items (describe) 11. Transfer to statement of income and retained earnings. _________ _________ _________ 12. Total of items 7 to 11 13. Fund carried forward at end of year- 13.1 Reserve for outstanding reported losses. 13.2 Reserve for losses incurred but not reported. c Revised as at 8th day of July, 2003 Page 31 FOURTH SCHEDULE Insurance (Forms) Regulations 13.3 Others (describe) Sub-total _________ _________ _________ 14. Total of items 12 and 13 _________ _________ _________ Notes: (i) Items should be net of outwards reinsurance. (ii) Line 6 should equal line 14. Notes Re Part F Underwriting Analysis Notes: 1. Column 2 should show all underwriting expense but not management expenses. 2. Column 8 should be shown before any IBNR provision. 3. Columns 13, 14 and 15 are to be completed in respect of 1980 underwriting year only. This return to be completed for each underwriting year, commencing with 1980, open during the financial year to which the whole of the Fourth Schedule relates. The 1980 underwriting year analysis will always include entries in columns 13, 14 and 15 until such time as all previous liability has been extinguished. Notes Re Part G: General business Summary of re-insurance ceded Notes: 1. This Schedule may be completed on an underwriting year basis if preferred, subsequent returns showing information for the next underwriting year together with any changes in coverage relating to earlier years. 2. Facultative re-insurance need only be included where the premium for any particular cover exceeds ten per cent of the gross premium for the class. 3. Cessions to other re-insurers may be grouped geographically, e.g. U.S. market, London market, Far East market, etc. Page 32 Revised as at 8th day of July, 2003 c Insurance (Forms) Regulations FOURTH SCHEDULE Part H AUDITORS CERTIFICATE WE HEREBY CERTIFY that the financial information contained in accompanying Annual Accounts has been prepared from the company’s records and audited annual accounts as at attached hereto. In our/my opinion the accompanying Annual Accounts presents fairly the information required under section 7(4) of the Insurance Law (2003 Revision). Dated at this day of , 20 . ……………………………………………………………………………………... [Signature of person[s] furnishing this certificate] ……………………………………………………………………………………... [Name and position of individual signing above certificate] Name of company………………………………………………………………… Address…………………………………………………………………………….. Publication in consolidated and revised form authorised by the Governor in Cabinet this 8th day of July, 2003. Carmena Watler Clerk of the Cabinet c Revised as at 8th day of July, 2003 Page 33