Application Under Freedom to Provide Services Pursuant to Article 78 of the Insurance Act

Croatian Financial Services Supervisory Agency

(HANFA)

Miramarska 24b

10000 Zagreb

Application under freedom to provide services pursuant to Article 78 of the Insurance Act

Undertaking:______

Registered office:______

Contact person (name, surname, phone, e-mail)______

______

Countries in which services are to be provided (please mark with an X):

Country / ISO code / Country / ISO code
Austria / AT / Norway / NO
Belgium / BE / Poland / PL
Bulgaria / BG / Portugal / PT
Cyprus / CY / Romania / RO
Czech Republic / CZ / Slovakia / SK
Denmark / DK / Slovenia / SI
Estonia / EE / Spain / ES
Finland / FI / Sweden / SE
France / FR / United Kingdom / GB
Germany / DE
Gibraltar / GI
Greece / GR
Hungary / HU
Iceland / IS
Ireland / IE
Italy / IT
Latvia / LV
Liechtenstein / LI
Lithuania / LT
Luxembourg / LU
Malta / MT
Netherlands / NL

Business operations shall be carried out via (please mark with an X)

a)The above undertaking

b)An EEA branch of the undertaking

The registered office of the branch is located at:______

Notification of the insurance classes for which the undertaking has a domestic licence pursuant to Article 3 of the Insurance Act and which are to be operated in the countries concerned:

Non-life insurance

Class / Name / Particular requirement / Please mark with X
1 / Accident
2 / Sickness
3 / Land vehicles (other than railway rolling stock)
4 / Railway rolling stock
5 / Aircraft
6 / Ships (see, lake and river, and canal vessels)
7 / Goods in transit
8 / Fire and natural forces
9 / Other damage to property
10 / Motor vehicle liability (vehicles operating on the land)
11 / Aircraft liability
12 / Liability for ships (see, lake and river, and canal vessels)
13 / General liability
14 / Credit
15 / Suretyship
16 / Miscellaneous financial loss
17 / Legal expenses / Please select option of Article 3(2) of Directive 87/344/EEC
18 / Assistance / Please provide details of organisation of assistance in the country of activity

Life assurance

Class / Name / Please mark with X
19, 20 and 21
(I.) / Life assurance, annuities and supplementary insurance in addition to life assurance
22 (II.) / Marriage insurance and birth insurance
23 (III.) / Life assurance and annuities which are linked to the investment funds
24 (V.) / Tontines
25 (VI) / Capital redemption operations
Other classes according to the Consolidated Life Directive 2002/83/EC

Other comments:

Date______

Signature and company stamp______