Detail

Back to Revised Laws of Saint Lucia (2023)

Schedule

(Regulations 4)
Form GR101
APPLICATION FOR REGISTRATION
PERSONAL PARTICULARS
(To be completed by every director or manager or partner, and should accompany an application for registration as an insurer, as an insurance agent or as an insurance broker.)
1.	Surname ..................................... Forename .............................................
2.	Private address .......................................................................................
3.	Business address .....................................................................................
4.	Date of birth ...................................	5.	Country of birth .......................
6.	Nationality ....................................	7.	Occupation ............................
8.	Position held in applicant firm .....................................................................
9.	Shareholding in the applicant company (if applicable) .........................................
10.	Professional training (including details of any insurance and related courses) (Attach original and photocopies of certificates). ........................................................................................................... ........................................................................................................... ...........................................................................................................

11.	Working experience in insurance. (Include dates and the class(es) of insurance transacted.) ........................................................................................................... ........................................................................................................... ...........................................................................................................
12.	Are you a member of an association of insurance salesmen or of any other professional insurance association? Give details. ........................................................................................................... ........................................................................................................... ...........................................................................................................
13.	Are you a director of any insurance company, insurance brokerage company or insurance agency? Give details. ........................................................................................................... ........................................................................................................... ...........................................................................................................
14.	Of what other bodies corporate are you a director or partner? ........................................................................................................... ........................................................................................................... ...........................................................................................................
15.	Have you at any time been convicted of any offence (other than a traffic offence) by any court whether civil or military? Give details. ........................................................................................................... ........................................................................................................... ...........................................................................................................
16.	Have you been censured, disciplined or publicly criticised by any professional body to which you belong or belonged or refused entry to any profession? If so, give particulars. ........................................................................................................... ........................................................................................................... ...........................................................................................................
17.	Have you been adjudged bankrupt by a court in Saint Lucia or elsewhere? If so give particulars. ........................................................................................................... ........................................................................................................... ...........................................................................................................
I, .................................................................... certify that I have supplied the above information and to the best of my knowledge and belief the information is true and complete.
Date .........................................		Signature .......................................

FORM C13

GOVERNMENT OF SAINT LUCIA
CERTIFICATE OF REGISTRATION
*as an*
INSURANCE AGENT
this is to certify that
.....................................................................
is registered under Part 5 of the Insurance Act as an INSURANCE AGENT representing the following Insurance Company
.....................................................................
in respect of the following classes of insurance business—
The officers/partners who may act in the name of the firm/company are—
....................................................		..........................................................
Date		Registrar of Insurance
Note:	This Certificate is valid for one year from the date of issue and shall be renewable annually on the anniversary date of issue.

FORM C14

GOVERNMENT OF SAINT LUCIA
CERTIFICATE OF REGISTRATION
*as an*
INSURANCE BROKER
this is to certify that
.....................................................................
is registered under Part 5 of the Insurance Act as an INSURANCE BROKER representing the following classes of Insurance Business—
The Officers/partners who may act in the name of the firm/company are—
......................................................	.......................................................
Date	Registrar of Insurance
Note: This Certificate is valid for one year from the date of issue and shall be renewable annually on the anniversary date of issue.

FORM C15

GOVERNMENT OF SAINT LUCIA
CERTIFICATE OF REGISTRATION
*as an*
INSURANCE SALESMAN
this is to certify that
.........................................................................
is registered under Part 5 of the Insurance Act as an INSURANCE SALESMAN for the following Insurance Company—
..................................................................................................................
and may procure business on their behalf in respect of the following classes of Insurance Business—
........................................................		........................................................
Date		Registrar of Insurance
Note:	This Certificate is valid for one year from the date of issue and shall be renewable annually on the anniversary date of issue.

FORM N010

NOTICE OF TERMINATION OF AGENCY

To the Registrar of Insurance

Please note that the agency agreement between:

...................................................................................................................

Name of Company and

...................................................................................................................

Name of Agent

has been terminated as of ....................................................................................

Date

for the following reasons:

...................................................................................................................

Signature ................................................

Title ................................................

(Chief Executive of the Company or of the Agency)

Date ................................................

FORM N011

NOTICE OF TERMINATION OF SALESMAN CONTRACT

To the Registrar of Insurance

Please note that the contract between:

...................................................................................................................

Name of Company and

Mr/Mrs/Miss ...................................................................................................

Salesman

has been terminated as at ...............................................................................

Date

for the following reasons:

...................................................................................................................

Signature ................................................

Title ................................................

(Chief Executive, Principal Representative of the)

Company, or Salesman

Date ................................................

FORM N012
NOTICE OF INSURANCE SALESMAN CONTRACT
To the Registrar of Insurance
Please note that with effect from .....................................................................
Date
Mr/Mrs/Miss ...................................................................................................
of ...............................................................................................................
Address
has entered into a contract with:
...................................................................................................................
Name of Company
to carry on the business of SALESMAN in respect of the following classes of insurance business:
1 .....................................................	2 ......................................................
3 .....................................................	4 ......................................................
5 .....................................................	6 ......................................................
7 .....................................................	8 ......................................................
Signature ................................................
Title ................................................
(Please affix the official stamp of the Company)
Date ................................................