| Please complete all parts of the application, attaching appendices where appropriate. |
| Is the insurance business of the Incorporated Cell Company “general' insurance business, 'long-term' insurance business or both? Please tick the appropriate box:- |
| Class A – General insurance business Subclass [ ] |
| Class B – Long-term insurance business Subclass [ ] |
| Class C – Long-term and General insurance business Subclass [ ] |
| Applicant Details |
| 1. | Name of Applicant |
| 2. | International Business Company No. and Date of Incorporation |
| 3. | Registered Office of Applicant |
| 4. | Business Address of Applicant |
| 5. | Contact person for this application |
| 6. | Telephone No.
Fax No.
Email address |
| Share Capital |
| 7. | Authorized | |
| 8. | Issued | |
| 9. | Paid-up | |
| 10. | Method of Capitalization | |
| Ownership Details |
| 11. | List all names (including any previous names) addresses and nationalities of all beneficial shareholders and ultimate beneficial shareholders (current/proposed) together with the number and class of shares (to be)held directly or on their behalf |
Name Address Nationality No. and class of shares
a)
b)
c)
d) |
| 12. | In those cases where the shares are beneficially owned by a corporate body or bodies, or the company is part of a group, the chain of connection (group organization chart showing all associated and affiliated companies) to the ultimate beneficial owners must be attached. | Attached:
Yes
No
N/A |
| 13. | Provide the latest audited financial statements of the applicant and immediate parent (and if applicable the consolidated accounts of the group). | Attached:
Yes
No
N/A |
| 14. | Detail the origin of source(s) of funds to support the incorporated cell company. | |
| Applicant's Personnel |
| 15. | Provide a list detailing the names and addresses of the current and proposed directors, officers, managers, consultants and administrators showing their respective positions with the applicant. A completed resume for each person should be attached. |
| Name and Title | Address | Resume Attached? |
| | Yes
No
Yes
No
Yes
No
Yes
No |
| Third Party Service Providers |
| 16. | List below any third party service providers including but not limited to intermediaries, claim handlers, and loss adjusters. State any connection between the applicant (including proposed directors and officers of applicant) and any person or organization remunerated directly or indirectly (e.g. insurance brokers etc) by the company. Further a copy of any service or management agreements is to be provided where the company's activities are to be managed by another party. |
| Insurance Business |
| 17. | Is the Incorporated Cell Company proposing to write insurance business other than through Incorporated Cells (that is, through the ICC itself)? | |
| 18. | On which date does the applicant wish to commence carrying on insurance within the ICC? | |
| 19. | If the company is not fully funded in the formative years, what provision is there in effect if there are early heavy losses? Please state fully how any risk gap is to be overcome. | |
| 20. | State whether the company proposes making any loans to its directors, managers, parent, associated or related companies. | |
| 21. | Please provide an organization chart showing details of all cells and the company's position within the structure. | |
| Accounts |
| 22. | Identify the company's financial year end. | |
| General |
| 23. | Have any of the parties connected with this applicant ever applied, either individually or in conjunction with others, for authority to transact insurance business in any other jurisdiction? If so, please give details. | |
| Additional Information to be Supplied |
| 24. | Copy of auditor's acceptance to act as auditor of the applicant (on headed paper including the name and address of the auditor attached? | Yes
No |
| 25. | Copy of Actuary's acceptance letter to act as Actuary of the applicant, where appropriate. | Yes
No |
| 26. | Applicant's Memorandum/Articles of Association attached? | Yes
No |
| 27. | Applicant's Certificate of Incorporation Attached? | Yes
No
To follow |
| Business Plan |
| 28. | Attach business plan – 5 year business plan and a statement of aims and programme of operations to include the sources of business, balance sheet, profit and loss projections and solvency calculations.
The assumptions underlying the projections should also be stated. |
| Fees |
| 29. | Ensure that the appropriate fee is enclosed with the application. |