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APPLICATION FORM: APPLICATION UNDER PART 3 (COMPOSITION, GOVERNANCE AND STRUCTURE OF THE BOARD OF DIRECTORS) OF BOARD NOTICE 158 OF 2014[1]
General instructions:
The application form must be completed with reference to the applicable Legal and Policy Framework that appears at the end of the application form.
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Insurer Name
Insurer Number
Type of application (please indicate with “x” for all the questions in the spaces provided below):
1. Application under the -
2. Application to use another committee performing the functions of –
(if another committee(s) will perform the functions of both the risk committee and the remuneration committee, both options must
be marked and sections completed)
2.1 Application in terms of section 7(5)(b) of Board Notice 158 of 2014 - Another committee performing the functions of the risk committee:
(indicate if not applicable)
2.1 </2.12.1.1 Reason for the audit committee not performing the functions of the risk committee as prescribed
2.1.1 </2.1.12.1.2 Provide the name of the committee that is to perform the functions of the risk committee
2.1.2 </2.1.22.1.3 Indicate the structure and composition of this committee (to be completed in Part 5)
2.2 Application in terms of section 7(5)(b) of Board Notice 158 of 2014 - Another committee performing the functions of the remuneration committee:
(indicate if not applicable)
2.2 </2.22.2.1 Reason for the audit committee not performing the functions of the remuneration committee as prescribed
2.2.1 </2.2.12.2.2 Provide the name of the committee that is to perform the functions of the remuneration committee
2.2.2 </2.2.22.2.3 Indicate the structure and composition of this committee (to be completed in Part 6)
Clearly indicate any attachments that have been included with this application form.
Description / Number of pagesAttachment A / Charter of the proposed committee / Ap /Ap
Attachment B / Most recent agenda/proposed agenda of the proposed committee / Bp /Bp
Attachment C / Minutes of the most recent meeting of the proposed committee / Cp /Cp
Attachment D / Self assessment by the proposed committee of its ability to adequately perform the duties as prescribed / Dp /Dp
Attachment E / E /E / Ep /Ep
Attachment F / F /F / Fp /Fp
Attachment G / G /G / Gp /Gp
Attachment H / H /H / Hp /Hp
Attachment I / I /I / Ip /Ip
Attachment J / <J /J / Jp /Jp
Attachment K / K /K / Kp /Kp
Attachment L / L /L / Lp /Lp
Attachment M / M /M / Mp /Mp
Instructions:
Please provide the details of the responsible person / public officer to whom the Registrar must direct all correspondence.
Full name and surname
Telephone number
E-mail address
I, 4.4 /4.4 [full name of responsible person / public officer], identity / passport number 4.5 /4.5 hereby certify, to the best of my knowledge, that the answers and information are complete, accurate, true and not misleading in any respect.
…………………………………………………………. …………………….
Signature of responsible person / public officer Date
We hereby confirm that this application and all information contained herein represent the views and express intentions of the board and audit committee.
……………………………….. …………………….
Signature of chairperson of the board Date
……………………………….. …………………….
Signature of CEO Date
……………………………….. …………………….
Signature of chairperson of the audit committee Date
Instructions:
Please provide the committee which will be fulfilling the duties as prescribed for the risk committee.
Full names of the members of the committee / Date of appointment / Identity/passport number / Position held / Independent/ not independent5.1a /5.1a / 5.1b
dd/mmm/yy /5.1b / 5.1c /5.1c / 5.1d /5.1d / 5.1e /5.1e
5.2a /5.2a / 5.2b
dd/mmm/yy /5.2b / 5.2c /5.2c / 5.2d /5.2d / 5.2e /5.2e
5.3a /5.3a / 5.3b
dd/mmm/yy /5.3b / 5.3c /5.3c / 5.3d /5.3d / 5.3e /5.3e
5.4a /5.4a / 5.4b
dd/mmm/yy /5.4b / 5.4c /5.4c / 5.4d /5.4d / 5.4e /5.4e
5.5a /5.5a / 5.5b
dd/mmm/yy /5.5b / 5.5c /5.5c / 5.5d /5.5d / 5.5e /5.5e
5.6a /5.6a / 5.6b
dd/mmm/yy /5.6b / 5.6c /5.6c / 5.6d /5.6d / 5.6e /5.6e
5.7a /5.7a / 5.7b
dd/mmm/yy /5.7b / 5.7c /5.7c / 5.7d /5.7d / 5.7e /5.7e
5.8a /5.8a / 5.8b
dd/mmm/yy /5.8b / 5.8c /5.8c / 5.8d /5.8d / 5.8e /5.8e
5.9a /5.9a / 5.9b
dd/mmm/yy /5.9b / 5.9c /5.9c / 5.9d /5.9d / 5.9e /5.9e
5.10a /5.10a / 5.10b
dd/mmm/yy /5.10b / 5.10c /5.10c / 5.10d /5.10d / 5.10e /5.10e
5.11a /5.11a / 5.11b
dd/mmm/yy /5.11b / 5.11c /5.11c / 5.11d /5.11d / 5.11e /5.11e
5.12a /5.12a / 5.12b
dd/mmm/yy /5.12b / 5.12c /5.12c / 5.12d /5.12d / 5.12e /5.12e
5.13a /5.13a / 5.13b
dd/mmm/yy /5.13b / 5.13c /5.13c / 5.13d /5.13d / 5.13e /5.13e
5.14a /5.14a / 5.14b
dd/mmm/yy /5.14b / 5.14c /5.14c / 5.14d /5.14d / 5.14e /5.14e
5.15a /5.15a / 5.15b
dd/mmm/yy /5.15b / 5.15c /5.15c / 5.15d /5.15d / 5.15e /5.15e
5.16a /5.16a / 5.16b
dd/mmm/yy /5.16b / 5.16c /5.16c / 5.16d /5.16d / 5.16e /5.16e
5.17a /5.17a / 5.17b
dd/mmm/yy /5.17b / 5.17c /5.17c / 5.17d /5.17d / 5.17e /5.17e
5.18a /5.18a / 5.18b
dd/mmm/yy /5.18b / 5.18c /5.18c / 5.18d /5.18d / 5.18e /5.18e
5.19a /5.19a / 5.19b
dd/mmm/yy /5.19b / 5.19c /5.19c / 5.19d /5.19d / 5.19e /5.19e
5.20a /5.20a / 5.20b
dd/mmm/yy /5.20b / 5.20c /5.20c / 5.20d /5.20d / 5.20e /5.20e
Instructions:
Please provide the committee which will be fulfilling the duties as prescribed for the remuneration committee.
Full names of the members of the committee / Date of appointment / Identity/passport number / Position held / Independent/ not independent6.1a /6.1a / 6.1b
dd/mmm/yy /6.1b / 6.1c /6.1c / 6.1d /6.1d / 6.1e /6.1e
6.2a /6.2a / 6.2b
dd/mmm/yy /6.2b / 6.2c /6.2c / 6.2d /6.2d / 6.2e /6.2e
6.3a /6.3a / 6.3b
dd/mmm/yy /6.3b / 6.3c /6.3c / 6.3d /6.3d / 6.3e /6.3e
6.4a /6.4a / 6.4b
dd/mmm/yy /6.4b / 6.4c /6.4c / 6.4d /6.4d / 6.4e /6.4e
6.5a /6.5a / 6.5b
dd/mmm/yy /6.5b / 6.5c /6.5c / 6.5d /6.5d / 6.5e /6.5e
6.6a /6.6a / 6.6b
dd/mmm/yy /6.6b / 6.6c /6.6c / 6.6d /6.6d / 6.6e /6.6e
6.7a /6.7a / 6.7b
dd/mmm/yy /6.7b / 6.7c /6.7c / 6.7d /6.7d / 6.7e /6.7e
6.8a /6.8a / 6.8b
dd/mmm/yy /6.8b / 6.8c /6.8c / 6.8d /6.8d / 6.8e /6.8e
6.9a /6.9a / 6.9b
dd/mmm/yy /6.9b / 6.9c /6.9c / 6.9d /6.9d / 6.9e /6.9e
6.10a /6.10a / 6.10b
dd/mmm/yy /6.10b / 6.10c /6.10c / 6.10d /6.10d / 6.10e /6.10e
6.11a /6.11a / 6.11b
dd/mmm/yy /6.11b / 6.11c /6.11c / 6.11d /6.11d / 6.11e /6.11e
6.12a /6.12a / 6.12b
dd/mmm/yy /6.12b / 6.12c /6.12c / 6.12d /6.12d / 6.12e /6.12e
6.13a /6.13a / 6.13b
dd/mmm/yy /6.13b / 6.13c /6.13c / 6.13d /6.13d / 6.13e /6.13e
6.14a /6.14a / 6.14b
dd/mmm/yy /6.14b / 6.14c /6.14c / 6.14d /6.14d / 6.14e /6.14e
6.15a /6.15a / 6.15b
dd/mmm/yy /6.15b / 6.15c /6.15c / 6.15d /6.15d / 6.15e /6.15e
6.16a /6.16a / 6.16b
dd/mmm/yy /6.16b / 6.16c /6.16c / 6.16d /6.16d / 6.16e /6.16e
6.17a /6.17a / 6.17b
dd/mmm/yy /6.17b / 6.17c /6.17c / 6.17d /6.17d / 6.17e /6.17e
6.18a /6.18a / 6.18b
dd/mmm/yy /6.18b / 6.18c /6.18c / 6.18d /6.18d / 6.18e /6.18e
6.19a /6.19a / 6.19b
dd/mmm/yy /6.19b / 6.19c /6.19c / 6.19d /6.19d / 6.19e /6.19e
6.20a /6.20a / 6.20b
dd/mmm/yy /6.20b / 6.20c /6.20c / 6.20d /6.20d / 6.20e /6.20e
INFORMATION RELATING TO AN APPLICATION UNDER PART 3 (COMPOSITION, GOVERNANCE AND STRUCTURE OF THE BOARD OF DIRECTORS) OF BOARD NOTICE 158 OF 2014
A. Introduction
This application form relates to an application under Part 3 (Composition, Governance and Structure of the Board of directors) of Board Notice 158 of 2014.
B. Interpretation/Legal framework
1. In the application form any word or expression defined in the Long-term Insurance Act, the Short-term Insurance Act or Board Notice 158 of 2015 (published in Government Gazette No. 38357 on 19 December 2014 in terms of section 12(1)(bD) of the Short-term Insurance Act No. 53 of 1998 and Long-term Insurance Act No. 52 of 1998), as the case may be, including any measure referred to in the definitions of “this Act” in sections 1(1) of the Acts, have, unless the context otherwise indicates, the meaning so defined.
2. Note that, if there is any discrepancy between the application form and the provisions of the Long-term Insurance Act, the Short-term Insurance Act or Board Notice 158 of 2015, as the case may be, the provisions in the Act or the Board Notice will be deemed correct.
3. In terms of Part 3 (Composition, Governance and Structure of the Board of Directors) of Board Notice 158 of 2014 the insurer may use another committee to perform the functions of the risk committee or remuneration committee or both if the Registrar approved the other committee.
C. Instructions
1. The application must be submitted directly to the Registrar of Long-term Insurance or Short-term Insurance at the Financial Services Board.
2. The application form must be completed in full by the responsible person and be signed by the person duly authorised to sign this form.
3. The application form must be completed with reference to the instructions provided in the application form and this information document in respect of each part of this form.
4. The format of the application form or the wording of questions may not be changed.
D. Additional Information
The Registrar, in accordance with section 4(2) of the Long-term Insurance Act and Short-term Insurance Act, may request additional information relating to the application.
[1] Published in Government Gazette No. 38357 on 19 December 2014 in terms of section 12(1)(bD) of the Short-term Insurance Act No. 53 of 1998 and Long-term Insurance Act No. 52 of 1998.