This Application Form Must Be Submitted by the Insurer Concerned Under Cover of a Letterhead

NOTIFICATION OF THE APPOINTMENT OR TERMINATION OR RESIGNATION OF THE APPOINTMENT OF A DIRECTOR OR MANAGING EXECUTIVE BY A LONG-TERM OR SHORT-TERM INSURANCE COMPANY TO THE REGISTRAR OF LONG-TERM OR SHORT-TERM INSURER

NOTIFICATION OF THE APPOINTMENT OR TERMINATION OF THE APPOINTMENT OR RESIGNATION OF A DIRECTOR OR MANAGING EXECUTIVE BY A LONG-TERM OR SHORT-TERM INSURER TO THE REGISTRAR OF LONG-TERM OR SHORT-TERM INSURANCE IN TERMS OF SECTION 18(1) OF THE LONG-TERM INSURANCE ACT OR THE SHORT-TERM INSURANCE ACT (“ACT”)

A.Instructions for completion and submission

1.This form must be properly completed and signed. Questions must be answered either in full or not applicable (“n/a”). The signer(s) must be duly authorised to furnish the information.

2.The format of this form or the wording of questions may not be changed. However, this form may be reproduced.

3.Answers may be in writing or may be typed.

3.1If the form is completed on a computer, -

(a)delete the solid lines in those areas provided for answers before the answers are typed or use the overtype mode whilst the answers are typed.

(b)rows may be inserted where insufficient space is provided for answers.

3.2If the form is completed by hand, should the space provided not be sufficient, the detail can be provided on a separate page, duly cross-referenced to the relevant question.

3.3If the form that is submitted contains any changes to typed or written information, those changes must be signed.

4.The completed form does not need to be accompanied by any number of copies.

B.General information

1.This form is required in terms of section 3(2)(b)(ii) of the Act read with section 18(1) of the Act.

2.The Registrar, in terms of section 4(2) of the Act, may by notice direct a long-term or short-term insurer (“insurer”) to furnish the Registrar, within a specified period, with specified additional information or documents.

3.Terms used in this document will have the same meaning as defined in the Act.

4.The information in this document is confidential and not available for inspection by the public.

C.Legal and policy framework

1.In terms of section 18(1) of the Act an insurer shall notify the Registrar of Long-term or Short-term Insurance, in the form and of the information required by the Registrar, in respect of every director or managing executive appointed by it or whose appointment has been terminated by it or who resigns, within 30 days after such appointment or termination, together with the reasons for any such termination or resignation.

2.In terms of section 18(2) of the Act any director or managing executive who resigns or whose appointment has been terminated by a long-term insurer shall, at the request of the Registrar, inform the Registrar in writing of any matter relating to the affairs of that insurer of which the director or managing executive became aware in the performance of his or her duties and which may prejudice the insurer’s ability to comply with the Act

D.Specific information

1.State the name of the insurer in connection with which this form is completed.

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2.Newly appointed director or managing executive.

2.1State the title, full forename(s) and surname.

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2.2Indicate the position held (e.g. director or managing executive).

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2.3List the qualifications and experience.

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2.4State the effective date of the appointment.

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3.Outgoing director or managing executive.

3.1State the title, full forename(s) and surname.

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3.2Indicate the position held (e.g. director or managing executive).

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3.3State the reason(s) for the termination or resignation.

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3.4State the effective date of the termination of the appointment or resignation.

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4.Are there any other information or documents that are relevant to this form?

1.If the answer is “Yes” kindly specify the information or documents.

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______

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5.We hereby enclose -

5.1a list of the names, initials, designations (e.g. executive director, non-executive director, chairperson) of the members of the board of directors and/or the executive management.

5.2a completed personal questionnaire and declaration by the newly appointed person, including the documents referred to therein.

5.3the other documents, if any, mentioned in the Part D in support of the information in this form.

6.We certify, to the best of our knowledge, that the information given in the answers to the above questions are complete, accurate and true and not misleading in any respect.

Full forename(s) and surname of public officer.

______

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SIGNATURE OF PUBLIC OFFICERDATE

Full forename(s) and surname of outgoing director/managing executive.

______

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OUTGOING DIRECTOR/MANAGING EXECUTIVEDATE

Full forename(s) and surname of newly appointed director/managing executive.

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NEWLY APPOINTED DIRECTOR/MANAGING EXECUTIVEDATE

Date of design of document: 01/08/2003Page 1