Monkton Insurance Services Limited

Application Forms - Barbados

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The application form for an Exempt Insurance Business Licence is prescribed by the Exempt Insurance Act, 1983. A copy of the application form follows.

APPLICATION is made on behalf of

for a licence to carry on from within Barbados the following class or classes of insurance business in accordance with the provision of the Exempt Insurance Act, 1983.

1. NAME OF COMPANY

2. ADDRESS of registered office in Barbados

Telephone No.

3. APPLICATION FEE paid to the Accountant General

Amount of Fee

Date and Receipt No.

4. PARTICULARS OF THE COMPANY

DATE OF INCORPORATION:

PLACE OF INCORPORATION:

SHARE CAPITAL:

AUTHORISED:

PAID-UP:

CONTRIBUTED RESERVES: (Applicable to Mutual Companies)

GUARANTEES:

AMOUNT:

NAME AND ADDRESS OF GUARANTOR:

SUMMARY OF MAIN OBJECTIVES:

5. MANAGEMENT

NAME AND ADDRESS of person resident in Barbados on whom documents may be served.


State whether the company will manage its own business or use the services of a management company.

NAME AND ADDRESS of management company in Barbados.

NAME AND ADDRESS of Auditors

(1) In Barbados




(2) Outside Barbados

NAME AND ADDRESS of Actuary

NAME AND ADDRESS of Bankers

(1) In Barbados




(2) Outside Barbados

6. BUSINESS PLAN

DATE OF COMMENCEMENT of Business

PROPOSED SOURCE OF BUSINESS - (BY CLASS)
(Name and addresses of affiliates must be given)

ESTIMATED GROSS PREMIUM INCOME (1st year)

ESTIMATED NET PREMIUM INCOME (1st year)

COMPANY'S FINANCIAL YEAR commences

ends

7. REINSURANCE PROGRAMME (by class)

8. SUPPORTING DOCUMENTS TO BE ATTACHED

• (1) Certified copy of certificate of incorporation under the Companies Act of Barbados.
  

• (2) Certified copy of Memorandum and Articles of Association.
  

• (3) Letters of acceptance of responsibility by persons resident in Barbados on whom documents may be served.
  

• (4) Auditors certificate in respect of paid up capital or contributed reserves.
  

• (5) Certified copy of Balance Sheet after incorporation and capitalisation.
  

• (6) Copy of contract with Management Company.
  

• (7) List of Directors, in respect of each Director state:
  - Full name
  - Permanent address
  - Country of birth
  - Nationality
  - Date of birth
  - Business experience
  - Other directorships held
  

• (8) Photocopy of Accountant General's receipt for application fee.
  

• (9) Copies of reinsurance cover notes and contracts.

We the undersigned do hereby certify that to the best of our knowledge the information submitted in this application and the supporting documents is true.

Signed by the Chairman of the Board of Directors


Signed by the Director, Resident in Barbados


Signed by the Company Secretary or Accountant.