Monkton
Insurance Services Limited
The Financial Services Supervision Department of the Cayman Islands requires that all prospective directors, shareholders, managers or controllers of captive insurance companies licensed in the Cayman Islands complete and submit a personal questionnaire. The following is a copy of that questionnaire. Each applicant is required to complete and sign an original copy which we will be happy to supply.
CAYMAN ISLANDS
FINANCIAL SERVICES SUPERVISION DEPARTMENT
Personal
Questionnaire for Directors, Shareholders, Managers and Controllers
THE BANKS AND TRUST COMPANIES LAW, 1989
THE INSURANCE LAW, 1979
THE MUTUAL
FUNDS LAW
THE COMPANIES MANAGEMENT LAW, 1984
1. Name of institution in connection with which this questionnaire
is being
completed.
2. Surname
Forename(s)
Any previous name(s) by which you have been
known.
3. Are you completing this questionnaire as a director, shareholder,
manager
or a controller. (see Note on page 4)
4. Private Address
5. Previous private addresses during the last ten years
(with relevant
dates)
6. Date of Birth
Place of birth (including town, state and country)
7. Nationality, and how it was acquired (e.g. birth, naturalisation,
marriage)
8. Present occupation or employment and occupations and
employment during
the last ten years, including the name
of the employer, the nature of the
business, the position
held and relevant dates.
9. Of what bodies corporate -
(a) are you now a director or controller?
(b) have you been a director or controller at any time
during the
last ten year?
(specify the country of incorporation in each case)
10. Professional qualifications and year in which they were
obtained.
11. Have you at any time been convicted of an offence (other
than (a)
an offence committed when you were under the
age of 18 years unless the
same was committed within the
last ten years, or (b) an offence in connection
with the use
or ownership of a motor vehicle which was tried in a court
of summary jurisdiction) by any court, whether civil or
military, in
any jurisdiction? If so, give full particulars of
the court by which you
were convicted, the offence and the
penalty imposed and the date of conviction.
12. Have you, anywhere, been censured, disciplined or
criticised by any
professional body to which you belong or
have belonged, or have you ever
held a practising
certificate subject to conditions? If so, give full particulars.
13. Have you, or any body corporate, partnership or
unincorporated institution
with which you are, or have
been associated as a director, shareholder,
manager or
controller, been the subject of an investigation, anywhere
by a governmental, professional or other regulatory body?
If so, give
full particulars.
14. Have you, anywhere, been dismissed from any office or
employment
or barred from entry to any profession or
occupation? If so, give full particulars.
15. Have you been adjudicated bankrupt by a court in any
jurisdiction?
If so, give full particulars.
16. Have you failed to satisfy any debt adjudged due and
payable by you
as a judgement-debtor under an order of a
court in any jurisdiction? If
so, give full particulars.
17. Have you, in connection with the formation, control or
management
of any body corporate, partnership or
unincorporated institution been adjudged
by a court, in any
jurisdiction, civilly liable for any fraud, misfeasance
or
other misconduct by you towards such a body or company
or towards
any members thereof? If so, give full particulars.
18. Has any body corporate, partnership or unincorporated
institution
with which you were associated as a director,
shareholder, manager or controller,
anywhere, been
compulsorily wound up or made any compromise or
arrangement with its creditors or ceased trading in
circumstances where
its creditors did not receive or have
not yet received full settlement of
their claims, either while
you were associated with it or within one year
after you
ceased to be associated with it? If so, give full particulars.
19. In carrying out your duties will you be acting on the
directions
or instructions of any other person? If so, give
full particulars.
I CERTIFY that the above information is complete and correct to the best of
my knowledge and belief and I undertake that, as long as I continue to be a director,
shareholder, manager, or controller of an institution authorised under the above
laws, I will notify the Inspector of Financial Services of any material changes affecting
the completeness of the answers to questions 11 - 18 above within a period of twenty-one
days.
Date ____________________________ Signed __________________________________
NOTE
CONTROLLERS
A controller includes
(1) any person who is entitled to exercise control of 15% or more of the voting power over the institution or over another company of which it is a subsidiary;
(2) any person, whether a shareholder or not, in accordance with whose directions or instructions the directors of the institution, or of another company of which it is a subsidiary, are accustomed to act.
When a controller is a body corporate the Inspector will look through that body to the ultimate controller from whom the above information will be sought.