Monkton Insurance Services Limited

Application Forms - Cayman

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The application form for a Class "B" Insurer's Licence is prescribed by the Insurance Law, 1979. A copy of the application form follows.

Please complete all sections as fully as possible, giving reasons for non-compliance if any, and attaching appendices where appropriate.

1. Name of applicant

2. Whether licence applied for is Restricted or Unrestricted

3. Date on which applicant commenced, or intends to commence, carrying on business in or from within the Islands

4. Whether business being, or proposed to be, transacted is "General" or "Long term" or both (as defined in section 2 of the Law)

5a. Address of principal office

5b. Address of registered office

6. If the applicant is to depend upon agent or service companies for the provision of underwriting, management, or financial accounting services, please give details of such companies including evidence of their agreement to provide the services mentioned.

7. Attached evidence of the proper incorporation of the applicant pursuant to section 4 of the Companies Law, and a copy of the memorandum of association and articles of association, or other instrument of constitution of the applicant, as may be appropriate or in the case of companies not yet incorporated, the proposed documentation

8. List all names (including any previous names), addresses and nationalities of all shareholders. In those instances where shares are held by a corporate body or bodies the chain of connection to the ultimate owner must be shown

8A.Attach the annual accounts, for the two years preceding the year of applciation, of each shareholder which is a body corporate holding more than ten percent of the applicant's issued share capital or total voting rights, together with similar accounts for the parent body, if any, of each such body corporate.

9. Attach curricula vitae of all directors, managers, and officers, including any previous names, and with particular emphasis on experience in the insurance profession

10. Attach not less than three references acceptable to the Authority, including one character reference for and one reference verifying the good financial standing of -
a) each director, manager and officer of the applicant; and
b) each shareholder and each beneficial shareholder who is a natural person holding more than ten percent of the applicant's issued share capital ot total voting rights;
and, for each such director, manager, officer or shareholder, a police or other certificate satisfactory to the Authority that such director, manager, officer or shareholder has not been convicted of a serious crime or any offence involving dishonesty.

11a. Name and address of the principal agent or representative resident in the Cayman Islands

11b. Address of designated principal office in the Islands where full business records will be kept

12. Name. address and professional qualification of auditors and the country whose generally accepted accounting principles are to apply. Attach evidence that said auditors have agreed to accept appointment

13. Name and address of person resident in the Cayman Islands who is authorised to accept service of process in legal proceedings and notices on behalf of the applicant and who is approved or proposed for approval under section 7(2) of the Law

14a. (For an existing insurer) Attach annual accounts for three years preceding the date of application

14b. (For an applicant for a new unrestricted class "B" insurer's licence) Attach a written undertaking to provide at least the minimum net worth requirements set out in section 4(9) of the Law, together with a statement as to how said net worth is to be calculated.

15. Attach a business plan. The Head of Insurance Supervision may indicate that any part of the information included in the business shall not form part of this application for the purpose of sections 4(3) and 7(3) of the Law

16. Have any of the parties connected with this application ever applied either individually of in conjunction with others, for authority to transact insurance business in any other jurisdiction? If so, please give details.

Application is accordingly hereby made for the licence specified above and it is certified that all the particulars contained in this Application and in the documents accompanying it or otherwise furnished in support hereof are true and correct.

Signed:_______________________________________

WITNESS:
Name:________________________________________

Occupation:____________________________________

Address:______________________________________

* Delete words which are not applicable

Please return with Licence Fee of CI$7,000 to the Cayman Islands Monetary Authority.