FORM C
APPLICATION FOR CHANGES IN REGISTRATION PARTICULARS
FOR GENERAL INSURANCE AGENT AND/OR GENERAL TAKAFUL AGENT
UNDER INSURANCE ORDER, 2006 (SECTION 48) AND TAKAFUL ORDER, 2008 (SECTION 49)
All sections to be completed accurately and legibly.
Managing Director
(Attn: Head of Takaful/Insurance Unit, Regulatory & Supervision Department)
Autoriti Monetari Brunei Darussalam
Level 14, Ministry of Finance Building
Commonwealth Drive, BB3910
Brunei Darussalam
* Applicable for changes in registration particulars during which the registration is still valid.
1.
Please tick (/) the appropriate box(es):
Change in business name
Change in registered office address
Additional principal
Ceased of principal
Additional Corporate Nominees
Change in Corporate Nominees
Change in shareholder, director, principal officer, or sole proprietor
Updates of qualification
Additional employees
Change of employees
Change from individual agent to corporate agent and vice versa
Open a branch / counter
2.
Name of Individual / Corporate Agent: ___________________________________________________
3.
Contact No:
___________________________________________________
4.
Signature:
___________________________________________________
5.
Date of Application:
___________________________________________________
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6.
Please fill in the information below (where the changes apply):
CHANGES IN PARTICULAR(S)
a)
Changes in Business Name:
f)
Updates of Qualification:
To fill in details in the supplementary sheet.
b)
Changes in Registered Office Address:
g)
i) Open of Counter / Branch Registered Address:
c)
List of Principals represented
(Additional or Ceased):
d)
Update details of shareholder, director,
principal officer, or sole proprietor:
To fill in details in the supplementary sheet.
e)
Corporate Nominee / Employees
(Additional or Resignation):
To fill in details in the supplementary sheet.
ii) Reason for opening counter / branch:
h)
Other changes in particular(s) not stated above:
Does the corporate nominee meet the fit and proper requirements as provided in the “Guidelines
on Fit and Proper Criteria for Key Responsible Persons in Insurance and Takaful” issued by
AMBD?
Yes
No
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DOCUMENTS REQUIRED
7.
Please tick to confirm the inclusion of the following documents, as applicable.
Individual Agent
Copy of Business Name Reserve Letter from Registrar of Companies (1 copy)
Copy of the Certificate of Registration (Section 16 & 17) from Registrar of Companies (1 copy)
Copies of Qualifications mentioned (1 copy)
Original copy of Clearance/Notification Letter endorsed by Brunei Insurance and Takaful Association
(BITA) (1 copy)
Copy of identity card for individual and employee(s) (1 copy)
Any documentation deems relevant.
Corporate Agent
Copy of Certificate of Incorporation from Registrar of Companies (1 copy)
Copy of the Memorandum of Association and Articles of Association (1 copy)
Copy of Form X (1 copy)
Copy of Notice of Situation of Registered Office (1 copy)
Copy of Notice of Change in the situation of Registered Office (1 copy)
Copies of qualifications mentioned (1 copy)
Original copy of Clearance/Notification Letter endorsed by Brunei Insurance and Takaful Association
(BITA) (1 copy)
Copy of identity card for shareholder(s) / Director(s), principal officers / corporate nominee(s) and
employees (1 copy)
Any documentation deems relevant
DECLARATION
I, ____________________________________ (Name of Individual Agent / Corporate Agent*) of I.C. Number
______________ declare that to the best of my knowledge and belief all the information given in this application
is true and correct.
Signature
Date
FOR AMBD USE ONLY
Serial No.:
I
C
Received on:
Issued by:
________________________
Verified by: ________________________
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