1 FORM NO .INS 150-3 APPLICATION FOR * REGISTRATION

FORM NO .INS 150-3
APPLICATION FOR * REGISTRATION / *RENEWAL OF REGISTRATION AS A/ *CLAIMS SETTLING
AGENT/*INSURANCE SURVEYOR/* LOSS ADJUSTERS/*INSURANCE INVESTIGATORS/*MOTOR
ASSESSORS/* RISK MANAGER
All amounts in Kenya Shillings
A. APPLICANT:
1. Name
2. Registered office:
Postal address
Telegraphic address
Telephone
Telex
3. Location of offices:
Principal
Branches at:
4. Incorporation:
Status * individual / partnership/ company
Place:
Date:
Insurance Business
Date of first license:
Date of commencement:
5. Particulars:
a) Member of board of Directors (Appendix A)
b) Principal Officer , Company Secretary and other Senior Management Staff (Appendix B)
c) Departmental staff(Appendix C)
d) Auditors ,legal advisers and actuaries (Appendix D)
e) Member of insurance industry whose services were availed of during the year( including
names of insurers with whom insurance business was placed ( Appendix E)
6. Bankers:
Name
Address
since when
1.
2.
3.
1
7.
i)
Does the applicant or a partner or director or an employee of the applicant directly or
indirectly hold shares in or have any other financial or controlling interests in the affairs of any
other member of the insurance industry?
ii)
Is any of the an individual or firms listed in appendices (D and E)
a) A director or employee of the applicant or s related company?
b) Holding any shares in, debentures of or other interests with the applicant or a related
company?
If so please give full particulars
8.
If the applicant is a company incorporated under the companies act, Cap .486 give the total
paid- up capital of the company
9.
Business particulars:
A) Number of years experience in the capacity in which registration is soughtB) Number of insurers for whom work done in the pastC) Do you handle any other workPertaining to insurance business?
Not pertaining to insurance business?
If the answer to the above is in the affirmative, give brief description of the work
handled.
I hereby certify that the statements contained herein are true and accurate to the best
of my knowledge and belief.
Any alterations in particulars stated herein must be promptly communicated to the
commissioner of insurance.
Signed on this
day of 20…..
2
Principal Officer
APPENDIX A TO FORM NO INS. 150-3
PARTICULARS OF BOARD OF DIRECTORS/PARTNERS
as at 31st December, 20………..
Name of
Serial
number
Full name
Citizenship
Residential
address
Occupation
Date of
appointment
Number of shares
held (see note 1
below)
Court conviction
(see note 2 below)
a
b
c
Interest in any member of
insurance industry (see item 7(1)
of sixteenth schedule)
Nature of
business
Name
1-------2-------3-------4-------5-------6-------Date
Principal Officer
Note: If the shareholding consists of two or more types of shares, details should be given separately to the type, number and total paid up values of each type of shares. If additional shares are held in
the names of any relatives (who are not directors themselves) of the director, particulars of the same should b e given separately.
1)
2)
Has there been in the pasta) Any conviction of an offence involving fraud or dishonesty?
b) Any adjudication as bankrupt or benefit taken of any law for the relief of bankrupt or insolvent debtors or compounding with creditors or assignment of remuneration for benefit of
creditors?
c)
Finding to be of unsound mind by a court of competent jurisdiction? Please state “YES” or “NO” in the above form and if the answer is “YES” give full details separately.
If the space herein is insufficient. Please use additional paper.
*Enter the relevant description from the under mentioned:
Claims settling agent/insurance surveyor/loss adjuster/Motor Assessor/Insurance Investigator/risk manager
3
Details of
interests
APPENDIX B TO FORM INS 150-3
PARTICULARS OF MANAGEMENT STAFF
As at 31st December 20…….
Name of
Serial
number
Full name
Designation
Citizenship
Residential
address
Qualification
Academic
Years of
experience
Professional
Date of
appointment
No of
shares
held
Court conviction
(see note 2 below)
(a)
b
Interests in any member
of insurance industry(
see item 7(i) of sixteenth
schedule
c
1……….
2……….
3……….
4……….
5……….
6……….
7……….
Date
Notes:
1.
2.
3.
Principal Officer
If the shareholding consists of two or more types of shares, details should be given separately of the type, number and total paid-up values of each type of shares. If additional shares are
held in the names of any relatives (which are not directors themselves) of the directors, particulars of the same should be given separately.
Has there been in the past:
(a)Any conviction of an offence involving fraud or dishonest.
(b)Any adjudications as bankrupt or benefit taken of any law for the relief of bankrupt or insolvent debtors or compounding with creditors or assignment of remuneration for benefit of
creditors.
(c)Finding to be of unsound mind by a court of competent jurisdiction? Please state “yes” or “No” in the above form and if the answer is yes give details separately.
If the space herein is insufficient, please use additional paper.
*Enter the relevant description from the under mentioned:
Claims settling agent/insurance surveyor/loss adjuster/Motor assessor/Insurance Investigator/risk manager
4
APPENDIX C TO FORM NO INS 150-3
PARTICULARS OF DEPARTMETAL STAFF
As at 31st December, 20………
Name of *
DEPARTMENT
MEMBER OF STAFF
Officers
Clerks
Stenographers/typ
ist
Messenger s
Others
Total
Number of staff who
are
not
Kenya
citizens(please
see
note 2 below)
Underwriting…………..
Claims……………………..
Administrations……….
Others (please specify)
Total ……………………….
Dates:
Principal Officer:
Notes:
1. If any management staff listed in appendix B is also included here, please indicate below as a note.
2. If any of the departmental staff is not a Kenyan citizen, please give the name, citizenship and the date of expiry of the work permit in a
separate statement.
3. If any of the departmental staff holds any qualifications such as A.C.I.I, F.C.I.I, A.C.A etc please give the name and professional qualifications in
a separate statement.
*Enter the relevant description from the under mentioned:
Claims settling agent/insurance surveyor/loss adjuster/Motor assessor/Insurance Investigator/risk manager
5
PARTICULARS OF AUDITORS, LEGAL AND ADVISERS AND ACTUARIES
as at 31st December, 20…….
Name of :
Name of firm
Address
Partners name
Auditors
1.
2.
3.
Legal advisors
1.
2.
3.
Actuaries
1.
2.
3.
Dates:
Principal Officer:
6
Professional qualifications
Since when
ANNEXURE III
TO CIRCULAR NO. IB 02/89
PARTICULARS OF PRINCIPAL OFFICER
1) Full name:
1) (a) Date of birth:
(b) Place of birth:
2) (a)Citizenship:
(b) ID card number:
3) Qualifications:
Academic:
Professional:
4) Work experience: please give dates and nature of work experience in previous employment:
5)
Have you ever been convicted of an offence involving fraud or dishonesty and if so, please give
details of the offence, place and date:
6)
Have you ever been adjudicated, bankrupt or applied to take the benefit of any law for the relief of
bankrupt or insolvent debtors compounded with your creators or made an assignment of your
remuneration for their benefit and if so please give detail:
7)
Are you a principal officer, a director or a shareholder or an employee of, or holding any controlling
interest in any other member of the insurance industry? If yes, please give full particulars:
Date
Principal Officer
7
APPENDIX E TO SIXTEENTH SCHEDULE
PARTICULARS OF MEMBERS OF INSURANCE INDUSTRY
As at 31st December, 20……..
Name of :
Member of the
insurance
industry (please
see note 1)
(1)
Name
Address
(2)
Nature of work
handled
(3)
(4)
Date:
Shareholding or
other interest
(please see note 2)
(5)
Registration
number
(6)
Principal Officer:
Notes:
1. State here broker, agent or any other capacity in which the member is registered under the act.
2. Please give information of number and type of shares held, amount of a shareholding and any
other interests as per item 7(ii) of sixteenth schedule.
3. If the space herein is insufficient, please use additional paper.
4. Please mention in column (6) the reference number of the registration under the insurance
Act,(cap.487)
*Enter the relevant description from the under mentioned:
Claims setting agent/ insurance surveyors/ Motor Assessor/Insurance Investigator/ loss adjusters/ risk
manager
8
FORM NO INS. 151-3
STATEMENT OF BUSINESS OF CLAIMS
SETTLING AGENT/ INSURANCE SURVEYOR/
LOSS ADJUSTER/MOTOR ASSESSOR/INSURANCE INVESTIGATOR/ RISK MANAGER*
( *Delete whichever are not applicable)
All amounts in Kenya shillings.
Year ending 31st December 20………
Name
Case of
business
(1)
Number of cases
Amount of fees
Number
handled.
of
Already
On
Total Received Outstanding Total insurers
to
completed hand (4)
(5)
(6)
(7)
whom
(2)
(3)
cases
handled
(8)
Largest
percentage of
cases for a single
insurer
(9)
TOTAL
Date
Principal Officer
Notes:
1. In cases of any assignments were handled on behalf of an overseas insurer, a statement giving the
number and nature of such assignments, amount of loss received and name of the currency it was
received should be enclosed.
2. The number of insurers in column (8) should not include the number of overseas insurers for whom
work may have been done(see note 1 above)
9
ANNEXURE II
TO CIRCULAR NO.II 01/89
PARTICULARS OF CASES HANDLED FROM
1ST JANUARY 20… TO 31ST DECEMBER 20….
Name:
INSURER
(OR BROKER)
December 20………………………
CLAIMS SETTLING
AGENT
No of
Amount
cases
of fees.
KShs.
INSURANCE
SURVEYOR
No of
No of
cases
cases
LOSS ADJUSTER
Motor ASSESSOR
Amount
of fees.
KShs
No of
cases
Amount
of fees.
KShs
Amount
of fees.
KShs
INSURANCE
INVESTIGATOR
No of
Amount
cases
of fees.
KShs
Total
Date
Principal Officer
10
RISK MANAGER
TOTAL
No of
cases
No of
cases
Amount of
fees.
KShs
Amount of
fees.
KShs