RETURNS FROM BROKERS FOR THE YEAR ENDED
____________ 20 ____ |
| 1. | Name: |
| 2. | Business Address: |
| 3. | Corporate Status: |
| 4. Premium Handled: (In respect of all arrangements other than Lloyds) |
| Class of Business | Paid to Insurers in St. Lucia | Paid to Insurers outside St. Lucia |
| Company Name | Direct | Reinsurance | Company Name | Direct | Reinsurance |
| Property | | | | | | |
| Marine, Aviation and Transport | | | | | | |
| Motor | | | | | | |
| Personal Accident | | | | | | |
| Liability | | | | | | |
| Pecuniary | | | | | | |
| Total – General Insurance | | | | | | |
| Ordinary Life | | | | | | |
| Industrial Life | | | | | | |
| Total Long-term Insurance | | | | | | |
| 5. Business Details – in respect of Lloyds Representatives\Cover Holders |
| Class of Business | Direct | Reinsurance |
| Premium Written | Claims Paid | Claims Outstanding | Premiums Paid | Claims Paid | Claims Outstanding |
| Property | | | | | | |
| Marine, Aviation and Transport | | | | | | |
| Motor | | | | | | |
| Personal Accident | | | | | | |
| Liability | | | | | | |
| Pecuniary Loss | | | | | | |
| Total | | | | | | |
| Ordinary Life | | | | | | |
| 6. Remuneration | |
| a) | Basis of remuneration in each class: | |
| b) | Actual income from brokerage and commissions during the year: | |
| 7. Powers: |
| a) | Do you hold a Power of Attorney or a binding authority from any insurer or group of underwriters? | |
| b) | If so give brief details (attach specimen). | |
| c) | Are you authorized to issue any documents (policies, cover notes, certificates etc.) to your clients? Give brief details. | |
| d) | Are you authorized to collect premiums and settle claims? If so give brief details of extent of authority. | |
| 8. Please state mode and periodicity of remittance of dues to insurers. |
| 9. Please provide information on premiums due to each insurer and list the aging of the sums outstanding. |
| 10. Do you work as a full-time broker? If it is conducted in conjunction with any other business, please give brief details (including agency representations of insurers, if any). |
| I/We hereby declare that the information given above are true and correct to the best of our knowledge and belief. |
| .................................................. |
| Signature |
| Date: |