THE SCHEDULE
Regulation 10
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM A
 
NAME OF INSURANCE BROKER _________________________________
BALANCE-SHEET AS AT ________________________
 
Co Code
 
Year
 
Month
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LIABILITIES
ROW NO.
$
ASSETS
ROW NO.
$
Shareholders’ fund —
 
 
 
 
 
Paid-up share capital
1
 
Cash and deposits
1
 
Unappropriated profits/(losses)
2
 
Insurance broking premium accounts
2
 
Reserves
3
 
Amounts owing from insurers and insureds
3
 
Total shareholders’ fund (1 to 3)
4
 
Investments
4
 
Other liabilities —
 
 
Fixed assets
5
 
Amounts owing to insurers and insureds
5
 
Other assets
6
 
Bank loans and overdrafts
6
 
 
 
 
Others
7
 
 
 
 
Total liabilities (4 to 7)
8
 
Total assets (1 to 6)
7
 
Contingent liabilities
9
 
 
 
 
Net asset value (4 – 9): $________________
Names and signatures of:
________________
Director
_________________
Director
_________________
Chief Executive Officer
Date: ________
Notes to Form A
      The following shall be stated as notes to this Form:
Note 1 Loans to and amounts due from employees of, or persons engaged by, the registered insurance broker to provide technical advice to its clients (please provide details on the date of loan and amount of loan granted to each person).
Note 2 Description in detail of the following items:
(a)Other assets (Asset Row 6);
(b)Reserves (Liability Row 3);
(c)Bank loans and overdrafts (Liability Row 6);
(d)Others (Liability Row 7); and
(e)Contingent liabilities (Liability Row 9).
 (state also the amounts applicable to each of the above items)
Note 3 Any changes in accounting policies and quantification of their effects.
Instructions for completion of Form A
1.All amounts shown in this Form are to be rounded up to the nearest dollar. Negative amounts shall be preceded by “—”.
2.Assets do not include any amount on account of goodwill and other intangible assets.
3.“Cash and deposits” refers to cash in hand and bank deposits which are not designated or evidenced as “Insurance broking premium accounts”.
4.“Insurance broking premium accounts” refers to the aggregate of the respective insurance broking premium accounts maintained in accordance with section 35ZD of the Act and any other insurance broking premium account required to be maintained by the insurance broker under any other written law in Singapore.
5.“Amounts owing from insurers and insureds” refers to premiums, claims moneys, brokerage and fees earned from the provision of consultancy and risk management services due from insurers and insureds.
6.“Amounts owing to insurers and insureds” refers to premiums and claims moneys owing to insurers and insureds.
7.“Fixed assets” includes land and buildings, motor vehicles and office equipment.
Regulation 10
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM B
 
NAME OF INSURANCE BROKER _______________________________________
 
INSURANCE BROKING PREMIUM ACCOUNT
FOR THE FINANCIAL YEAR _____________ TO ______________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Direct Insurance Broking
 
 
 
 
 
 
 
 
General Reinsurance Broking
 
 
Co Code
 
Year
 
Month
 
Life Reinsurance Broking
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(Tick (√) one only)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ROW NO.
$
 
 
PART I
 
 
 
 
BALANCE OF ACCOUNT AT BEGINNING OF FINANCIAL YEAR
 
 
 
 
      Bank account
1
 
 
 
      Deposits
2
 
 
 
TOTAL (1 to 2)
3
 
 
 
PART II
 
 
 
 
INSURANCE BROKING PREMIUM ACCOUNT TRANSACTIONS
 
 
 
 
Moneys Received During Financial Year
—————————————————
 
 
 
 
Premiums
4
 
 
 
Claims moneys
5
 
 
 
Proceeds from deposits
6
 
 
 
Others
7
 
 
 
TOTAL MONEYS RECEIVED (4 to 7)
8
 
 
 
Moneys Withdrawn During Financial Year
—————————————————
 
 
 
 
Premiums
9
 
 
 
Claims moneys
10
 
 
 
Brokerage
11
 
 
 
Deposits
12
 
 
 
Other approved withdrawals
13
 
 
 
TOTAL MONEYS WITHDRAWN (9 to 13)
14
 
 
 
PART III
 
 
 
 
BALANCE OF ACCOUNT AT END OF FINANCIAL YEAR
 
 
 
 
      Bank account
15
 
 
 
      Deposits
16
 
 
 
TOTAL (15 to 16)
17
 
 
 
 
 
Names and signatures of 2 Directors:
____________________________
____________________________
Name and signature of Chief Executive Officer:
_____________________________
Date:
_____________________________
Notes to Form B
      The following shall be stated as notes to this Form:
Note 1Name of bank(s) and account number(s) of the Insurance Broking Premium Account.
Note 2Details of deposits with banks (ie. name of bank, account number and amount).
Note 3Breakdown for the following items:
(a)  Others (Row 7); and
(b)  Other approved withdrawals (Row 13).
Instructions for completion of Form B
1.A registered insurance broker shall complete separate forms for each type of registration.
2.All amounts shown in this Form are to be rounded up to the nearest dollar. Negative amounts shall be preceded by “—”.
3.“Deposits” refers to deposits placed with any bank licensed under the Banking Act (Cap. 19).
4.“Proceeds from deposits” refers to the principal sum and interest received from the maturity or withdrawal of deposits.
5.“Other approved withdrawals” refers to other moneys which have been approved for withdrawal by the Authority.
 
Regulation 10
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM C
 
NAME OF INSURANCE BROKER ________________________________
 
PROFIT AND LOSS ACCOUNT
FOR THE FINANCIAL YEAR ______________TO _____________
 
 
Co Code
 
Year
 
Month
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ROW NO.
$
 
 
Brokerage earned from its insurance broking activity:
 
 
 
 
      Direct insurance broking
1
 
 
 
      General reinsurance broking
2
 
 
 
      Life reinsurance broking
3
 
 
 
Total brokerage (1 to 3)
4
 
 
 
Other revenue
5
 
 
 
Deduct     :  Staff salaries and related expenses
6
 
 
 
:  Other expenses
7
 
 
 
Add          :  Other income
8
 
 
 
Profit before tax
9
 
 
 
Deduct       :  Taxation
10
 
 
 
Profit after tax
11
 
 
 
Add            :  Extraordinary items
12
 
 
 
                   :  Unappropriated profits or accumulated losses brought forward from preceding financial year.
13
 
 
 
Deduct       :  Dividends
14
 
 
 
                   :  Transfers to reserves
15
 
 
 
                   :  Amounts capitalised
16
 
 
 
Unappropriated profits or accumulated losses at end of financial year
17
 
 
 
 
 
 
 
 
Names and signatures of 2 Directors:
____________________
 
 
____________________
 
Name and signature of Chief Executive Officer:
____________________
 
Date:
____________________
 
 
 
 
Notes to Form C
 
   The following shall be stated as notes to this Form:
 
Note 1 Breakdown for the following items:
 
(a)Other revenue (Row 5);
 
(b)Other expenses (Row 7); and
 
(c)Other income (Row 8).
 
 
 
Instructions for completion of Form C
 
1.All amounts shown in this Form are to be rounded up to the nearest dollar. Negative amounts shall be preceded by “—”
 
2.“Brokerage” refers to income, profit commissions and fees earned in relation to the insurance broking business carried out by the registered insurance broker.
 
3.“Other revenue” refers to income from financial advisory activities and fees earned from provision of consultancy and risk management services.
 
4.“Staff salaries and related expenses” includes —
 
(a)Salaries, bonuses and allowances;
(b)Director’s fees;
(c)CPF contributions, pensions and gratuities;
(d)Medical fees;
(e)Training; and
(f) Skills development levy.
 
 
 
 
 
Regulation 10
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM D
 
NAME OF INSURANCE BROKER ________________________________________
 
PLACEMENT OF BUSINESS HANDLED
FOR THE FINANCIAL YEAR ____________ TO _____________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Direct Insurance Broking
 
 
 
 
 
 
 
 
General Reinsurance Broking
 
 
Co Code
 
Year
 
Month
 
Life Reinsurance Broking
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(Tick (√) one only)
 
 
 
 
 
 
 
 
 
 
 
 
$
 
 
Premiums
Domestic Risks
Offshore Risks
Total
 
 
(a)  Registered insurers
 
 
 
 
 
(b)  Foreign insurers under the Foreign Insurers Scheme
 
 
 
 
 
      — under the Insurance (Lloyd’s Asia Scheme) Regulations
 
 
 
 
 
      — under the Insurance (Lloyd’s Scheme) Regulations
 
 
 
 
 
(c)  marine mutual insurers
 
 
 
 
 
     — in Singapore
 
 
 
 
 
     — outside Singapore
 
 
 
 
 
(d)  Other insurers
 
 
 
 
 
       Total
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Names and signatures of :
_________
Director
_________
Director
__________________
Chief Executive Officer
Date: _________________
 
 
Instructions for completion of Form D
1.A registered insurance broker shall complete separate forms for each type of registration.
2.All amounts shown in this Form are to be rounded up to the nearest dollar. Negative amounts shall be preceded by “—”.
3.“Domestic Risks” is a risk which would have been classified as a “Singapore Policy” as defined in paragraph 2(1) of the First Schedule to the Insurance Act (Cap. 142) had the risk been underwritten by a registered insurer.
4.“Offshore Risks” refers to any risk other than a Domestic Risk.
5.“Premiums” refers to premiums received or receivable during the financial year. Brokerage shall not be deducted from premiums.
6.“Registered insurers” excludes marine mutual insurers in Singapore.
 
ANNEX 1 TO FORM D
 
NAME OF INSURANCE BROKER ________________________________________
 
TOP 5 INSURERS WITH WHOM BUSINESS WAS PLACED FOR FINANCIAL YEAR ____________ TO _____________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Direct Insurance Broking
 
 
 
 
 
 
 
 
 
 
 
Co Code
 
Year
 
Month
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Name of Insurer
% of Total Domestic Gross Premiums Handled
 
 
1.
 
 
 
2.
 
 
 
3.
 
 
 
4.
 
 
 
5.
 
 
 
 
 
 
 
 
 
 
 
Name of Insurer
% of Total Offshore Gross Premiums Handled
 
 
1.
 
 
 
2.
 
 
 
3.
 
 
 
4.
 
 
 
5.
 
 
 
 
 
 
Note: “Top 5 insurers” means the 5 insurers with whom the largest volume of the registered insurance broker’s business was placed.
 
ANNEX 2 TO FORM D
 
NAME OF INSURANCE BROKER _____________________________________
 
SOURCE AND PLACEMENT OF
REINSURANCE PREMIUMS HANDLED
FOR FINANCIAL YEAR ____________ TO _____________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
General Reinsurance Broking
 
 
Co Code
 
Year
 
Month
 
Life Reinsurance Broking
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(Tick (√) one only)
 
 
 
 
 
 
 
 
 
 
 
PART A: SOURCE OF BUSINESS
 
 
 
 
$
 
 
Territory
Row
Offshore Risks
 
 
Australia/New Zealand
1
 
 
 
Hong Kong
2
 
 
 
Indonesia
3
 
 
 
Japan
4
 
 
 
Korea
5
 
 
 
Malaysia
6
 
 
 
Philippines
7
 
 
 
Taiwan
8
 
 
 
Thailand
9
 
 
 
________________
10
 
 
 
________________
11
 
 
 
________________
12
 
 
 
________________
13
 
 
 
________________
14
 
 
 
________________
15
 
 
 
________________
16
 
 
 
Others
17
 
 
 
Total
18
 
 
 
 
 
 
 
 
PART B: PLACEMENT OF BUSINESS WITH INSURERS
OUTSIDE SINGAPORE (EXCLUDING FOREIGN INSURERS
UNDER THE FOREIGN INSURERS SCHEME AND
PROTECTION AND INDEMNITY CLUBS)
 
 
 
 
 
$
 
 
Territory
Row
Domestic Risks
Offshore Risks
 
 
Australia/New Zealand
1
 
 
 
 
Denmark
2
 
 
 
 
France
3
 
 
 
 
Hong Kong
4
 
 
 
 
Indonesia
5
 
 
 
 
Italy
6
 
 
 
 
Japan
7
 
 
 
 
Korea
8
 
 
 
 
Malaysia
9
 
 
 
 
Philippines
10
 
 
 
 
Switzerland
11
 
 
 
 
Taiwan
12
 
 
 
 
Thailand
13
 
 
 
 
United Kingdom
14
 
 
 
 
United States
15
 
 
 
 
________________
16
 
 
 
 
________________
17
 
 
 
 
________________
18
 
 
 
 
________________
19
 
 
 
 
________________
20
 
 
 
 
________________
21
 
 
 
 
________________
22
 
 
 
 
________________
23
 
 
 
 
Others
24
 
 
 
 
Total
25
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Instructions for completion of Annex 2 to Form D
      A registered insurance broker shall complete separate forms for each type of registration.
 
 
 
PART A :   SOURCE OF BUSINESS
 
1.The classification of territory shall be by country of domicile of reinsureds.
 
2.For those countries which are not listed under Rows 1 to 9 and the reinsurance premiums sourced from each country amounts to —
(a)5% or more of total premiums for Offshore Risks, please list down the countries under Rows 10 to 16 and specify the amount of premiums sourced from each country; or
(b)less than 5% of total premiums for Offshore Risks, please provide the aggregate premiums sourced from all these countries under Row 17.
 
 
 
PART B :   PLACEMENT OF BUSINESS WITH INSURERS OUTSIDE SINGAPORE (EXCLUDING FOREIGN INSURERS UNDER THE FOREIGN INSURERS SCHEME AND PROTECTION AND INDEMNITY CLUBS)
1.For those countries which are not listed under Rows 1 to 15 and the reinsurance premiums placed with each country amounts to —
(a)5% or more of total premiums for Domestic Risks or Offshore Risks, as the case may be, please list down the countries under Rows 16 to 23 and specify the amount of premiums for Domestic Risks or Offshore Risks, as the case may be, placed with each country; or
(b)less than 5% of total premiums for Domestic Risks or Offshore Risks, as the case may be, please provide the aggregate premiums for Domestic Risks or Offshore Risks, as the case may be, placed with all these countries under Row 24.
 
Regulation 11
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM E
 
NOTICE OF COMMENCEMENT OF
INSURANCE BROKING BUSINESS
1.Name of corporation:
____________________________
2.Business address:
____________________________
3.Telephone number:
____________________________
4.Fax number:
____________________________
5.E-mail address:
____________________________
6.Company/business registration number:
____________________________
7.Paid-up capital (based on latest audited accounts ended __________________):
____________________________
8.Net asset value (based on latest audited accounts ended __________________):
____________________________
9.Status of exempt insurance broker:
(a) For persons licensed, approved or registered by the Monetary Authority of Singapore (“MAS”), please indicate status:
 □  Bank
 □  Merchant Bank
 □  Licensed Financial Adviser
 □  Holder of a Capital Markets Services Licence
 □  Finance Company
 □  Direct Life Insurer
(b)For others, please elaborate __________________________
10.  Please indicate type of insurance broking activity carried out:
 □  Direct Insurance Broking
 □  General Reinsurance Broking
 □  Life Reinsurance Broking
11.  Please provide a copy of your corporation’s organisation chart detailing key staff and reporting lines and specify the senior management staff member(s) with supervisory responsibility over the corporation’s direct insurance/general reinsurance/life reinsurance* broking operations.
12.  If the exempt insurance broker is not licensed, approved or registered by the MAS, please provide the following:
(a)Particulars of its substantial shareholders holding 5% or more of the share capital of the corporation:
 
 
 
 
 
 
 
Name
Percentage Shareholding
Identity card/ passport/UIN no. (for Singapore permanent resident)
Business/
Residential address
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(b)  In relation to each substantial shareholder, please furnish details of the nature of business, directorship and substantial shareholdings in other corporations in Singapore or elsewhere, and in the case of any individual, the curriculum vitae.
(c)  Particulars of key officers who are not substantial shareholders:
 
 
 
 
 
 
 
Name
Designation
Identity card/ passport/UIN no. (for Singapore permanent resident)
Residential address
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(d)  In relation to each key officer, please furnish a copy of his/her curriculum vitae. If the key officer(s) hold(s) any directorship or substantial shareholdings in any other corporation in Singapore or elsewhere, please give details of the corporation, nature of business, date and nature of appointment as director.
 
13.Date of commencement of insurance broking business:
______________________________
                      (dd/mm/yy)
 
Signature
:
______________________________
 
Name of Director/Secretary/
Principal Officer/Chief Executive Officer*
:
______________________________
 
Date
:
______________________________
                      (dd/mm/yy)
Note:
Please tick (√) in the relevant boxes where appropriate.
*Delete whichever is inapplicable.
 
Regulation 11
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM F
 
NOTICE OF CHANGE OF PARTICULARS
 
Name of corporation:
(If its name has been changed, state its name as previously furnished):
__________________________
 
 
Company/business registration number:
__________________________
 
      Notice is hereby given that on _____________________________(dd/mm/yy), the following particulars of the abovementioned corporation have been changed (Note: only those particulars which have changed need to be completed):
 
1.Indicate which of the following insurance broking activity is carried out:
 
 
Old Activity
Current Activity
 
Direct Insurance Broking
 
General Reinsurance Broking
 
Life Reinsurance Broking
2.If a new type of insurance broking activity is carried out, please provide a copy of your corporation’s organisation chart detailing key staff and reporting lines and specify the senior management staff member(s) with supervisory responsibility over the corporation’s direct insurance/general reinsurance/life reinsurance* broking operations.
3.If the exempt insurance broker is licensed, approved or registered by the Monetary Authority of Singapore (“MAS”), please indicate any change in status:
 □  Bank
 □  Merchant Bank
 □  Licensed Financial Adviser
 □  Holder of a Capital Markets Services Licence
 □  Finance Company
 □  Direct Life Insurer
4.If the exempt insurance broker is not licensed, approved or registered by the MAS, please update the following information, where applicable:
(a)Name of corporation
:
___________________
(b)Business address
:
___________________
(c)Telephone number
:
___________________
(d)Fax number
:
___________________
(e)E-mail address
:
___________________
(f)Company/business registration number
:
___________________
(g)Paid-up capital
 (as at ________________)
:
___________________
(h)Particulars of its substantial shareholders holding 5% or more of the share capital of the corporation:
 
 
 
 
 
 
 
 
Name
Percentage Shareholding
Identity card/ passport/UIN no. (for Singapore permanent resident)
Business/
Residential address
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(i)In relation to each substantial shareholder, please furnish details of the nature of business, directorship and substantial shareholdings in other corporations in Singapore or elsewhere, and in the case of any individual, the curriculum vitae.
(j)Particulars of key officers who are not substantial shareholders:
 
 
 
 
 
 
 
Name
Designation
Identity card/ passport/UIN no. (for Singapore permanent resident)
Residential address
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(k)In relation to each key officer, please furnish a copy of his/her curriculum vitae. If the key officer(s) hold(s) any directorship or substantial shareholdings in any other corporation in Singapore or elsewhere, please give details of the corporation, nature of business, date and nature of appointment as director.
 
Signature
:
___________________________
 
Name of Director/
Secretary/Principal Officer/
Chief Executive Officer*
:
___________________________
 
Date
:
___________________________
 
 
 
                   (dd/mm/yy)
 
 
 
 
   Note:
   Please tick (√) in the relevant boxes where appropriate.
   *Delete whichever is inapplicable.
 
Regulation 11
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM G
 
NOTICE OF INTENTION TO CEASE
INSURANCE BROKING BUSINESS
1.Name of corporation
:
__________________
2. Business address
:
__________________
3.Telephone number
:
__________________
4.Fax number
:
__________________
5.E-mail address
:
__________________
6.Company/business registration number
:
__________________
7.Please provide information on the arrangement(s) made to provide for orderly run-off of the corporation’s insurance broking business.
8.Proposed date of cessation of corporation’s insurance broking business:
 
 
 
___________________
 
 
(dd/mm/yy)
 
 
 
 
 
 
Signature                                     :________________
 
Name of Director/
Secretary/Principal Officer/
Chief Executive Officer*           :_________________
 
Date                                            :_________________
                                                            (dd/mm/yy)
*Delete whichever is inapplicable.
 
 
Regulation 11
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM H
 
NAME OF EXEMPT INSURANCE BROKER __________________________
 
INSURANCE BROKING PREMIUM ACCOUNT
FOR THE FINANCIAL YEAR _____________ TO _____________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Direct Insurance Broking
 
 
 
 
 
 
 
 
General Reinsurance Broking
 
 
Co Code
 
Year
 
Month
 
Life Reinsurance Broking
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(Tick (√) one only)
 
 
 
 
 
 
 
 
 
 
 
ROW NO.
$
PART I
 
 
BALANCE OF ACCOUNT AT BEGINNING OF FINANCIAL YEAR
 
 
 Bank account
1
 
 Deposits
2
 
TOTAL (1 to 2)
3
 
PART II
 
 
INSURANCE BROKING PREMIUM ACCOUNT TRANSACTIONS
 
 
Moneys Received During Financial Year
_______________________
 
 
Premiums
4
 
Claims moneys
5
 
Proceeds from deposits
6
 
Others
7
 
TOTAL MONEYS RECEIVED (4 to 7)
8
 
Moneys Withdrawn During Financial Year
_______________________
 
 
Premiums
9
 
Claims moneys
10
 
Brokerage
11
 
Deposits
12
 
Other approved withdrawals
13
 
TOTAL MONEYS WITHDRAWN (9 to 13)
14
 
PART III
 
 
BALANCE OF ACCOUNT AT END OF FINANCIAL YEAR
 
 
 Bank account
15
 
 Deposits
16
 
TOTAL (15 to 16)
17
 
 
Signature                                     :_________________
 
Name of Director/
Secretary/Principal Officer/
Chief Executive Officer*           :_________________
 
Date                                            :_________________
                                                            (dd/mm/yy)
 
 
AUDITORS’ CERTIFICATION OF FORM H
FOR FINANCIAL YEAR ______________ TO _______________
 
1.We have examined the insurance broking premium account for the financial year.
2.In our opinion and to the best of the information and according to the explanations given to us, the insurance broking premium account has been prepared in accordance with the provisions of the Insurance Act (Cap. 142) and any regulations made thereunder.
3.As far as can be ascertained from our examination, in our opinion, the insurance broking premium account has been established and maintained in accordance with section 35ZD of the Insurance Act; except
_________________________ (Firm)
 
Public Accountants and Chartered Accountants
Singapore
 
Date: ____________________
*Delete whichever is inapplicable.
 
Notes to Form H
 The following shall be stated as notes to this Form:
Note1 Name of bank(s) and account number(s) of the Insurance Broking Premium Account.
Note2 Details of deposits with banks (ie. name of bank, account number and amount).
Note3 Breakdown for the following items:
(a)Others (Row 7); and
(b)Other approved withdrawals (Row 13).
Instructions for completion of Form H
      1. An exempt insurance broker shall complete separate forms for each type of insurance broking business handled.
      2. All amounts shown in this Form are to be rounded up to the nearest dollar. Negative amounts shall be preceded by “—”.
      3. “Deposits” refers to deposits placed with any bank licensed under the Banking Act (Cap. 19).
      4. “Proceeds from deposits” refers to the principal sum and interest received from the maturity or withdrawal of deposits.
      5. “Other approved withdrawals” refers to other moneys which have been approved for withdrawal by the Authority.
 
Regulation 11
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM I
 
NAME OF EXEMPT INSURANCE BROKER __________________________
 
PLACEMENT OF BUSINESS HANDLED
FOR THE FINANCIAL YEAR _____________ TO _____________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Direct Insurance Broking
 
 
 
 
 
 
 
 
General Reinsurance Broking
 
 
Co Code
 
Year
 
Month
 
Life Reinsurance Broking
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(Tick (√) one only)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
$
 
 
Premiums
Domestic Risks
Offshore Risks
Total
 
 
(a)Registered insurers
 
 
 
 
 
(b)Foreign insurers under the Foreign Insurers Scheme
 
 
 
 
 
 — under the Insurance (Lloyd’s Asia Scheme) Regulations
 
 
 
 
 
 — under the Insurance (Lloyd’s Scheme) Regulations
 
 
 
 
 
(c)marine mutual insurers
 
 
 
 
 
 — in Singapore
 
 
 
 
 
 — outside Singapore
 
 
 
 
 
(d)Other insurers
 
 
 
 
 
Total
 
 
 
 
 
 
 
 
 
 
 
Signature                                     :_________________
 
Name of Director/
Secretary/Principal Officer/
Chief Executive Officer*           :_________________
 
Date                                            :_________________
                                                              (dd/mm/yy)
* Delete whichever is inapplicable.
 
Instructions for completion of Form I
1.An exempt insurance broker shall complete separate forms for each type of registration.
2.All amounts shown in this Form are to be rounded up to the nearest dollar. Negative amounts shall be preceded by “—”.
3.“Domestic Risks” is a risk which would have been classified as a “Singapore policy” as defined in paragraph 2(1) of the First Schedule to the Insurance Act (Cap. 142) had the risk been underwritten by a registered insurer.
4.“Offshore Risks” refers to any risk other than a Domestic Risk.
5.“Premium” refers to premiums received or receivable during the financial year. Brokerage shall not be deducted from premiums.
6.“Registered insurers” excludes marine mutual insurers in Singapore.
 
ANNEX 1 TO FORM I
 
NAME OF EXEMPT INSURANCE BROKER _________________________
 
TOP 5 INSURERS WITH WHOM BUSINESS WAS PLACED
FOR FINANCIAL YEAR ____________ TO _____________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Direct Insurance Broking
 
 
Co Code
 
Year
 
Month
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Name of Insurer
% of Total Domestic Gross Premiums Handled
 
 
1.
 
 
 
2.
 
 
 
3.
 
 
 
4.
 
 
 
5.
 
 
 
 
 
 
 
 
 
 
 
Name of Insurer
% of Total Offshore Gross Premiums Handled
 
 
1.
 
 
 
2.
 
 
 
3.
 
 
 
4.
 
 
 
5.
 
 
 
 
 
 
Note: “Top 5 insurers” means the 5 insurers with whom the largest volume of the registered insurance broker’s business was placed.
 
ANNEX 2 TO FORM I
 
NAME OF EXEMPT INSURANCE BROKER _________________________
 
SOURCE AND PLACEMENT OF
REINSURANCE PREMIUMS HANDLED
FOR FINANCIAL YEAR ____________ TO _____________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
General Reinsurance Broking
 
 
Co Code
 
Year
 
Month
 
Life Reinsurance Broking
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(Tick (√) one only)
 
 
 
 
 
 
 
 
 
 
 
PART A: SOURCE OF BUSINESS
 
 
$
 
 
Territory
Row
Offshore Risks
 
 
Australia/New Zealand
1
 
 
 
Hong Kong
2
 
 
 
Indonesia
3
 
 
 
Japan
4
 
 
 
Korea
5
 
 
 
Malaysia
6
 
 
 
Philippines
7
 
 
 
Taiwan
8
 
 
 
Thailand
9
 
 
 
_______________
10
 
 
 
_______________
11
 
 
 
_______________
12
 
 
 
_______________
13
 
 
 
_______________
14
 
 
 
_______________
15
 
 
 
_______________
16
 
 
 
Others
17
 
 
 
Total
18
 
 
 
 
 
 
 
PART B: PLACEMENT OF BUSINESS WITH INSURERS
OUTSIDE SINGAPORE (EXCLUDING FOREIGN INSURERS
UNDER THE FOREIGN INSURERS SCHEME AND
PROTECTION AND INDEMNITY CLUBS)
 
 
 
 
$
 
 
Territory
Row
Domestic Risks
Offshore Risks
 
 
Australia/New Zealand
1
 
 
 
 
Denmark
2
 
 
 
 
France
3
 
 
 
 
Hong Kong
4
 
 
 
 
Indonesia
5
 
 
 
 
Italy
6
 
 
 
 
Japan
7
 
 
 
 
Korea
8
 
 
 
 
Malaysia
9
 
 
 
 
Philippines
10
 
 
 
 
Switzerland
11
 
 
 
 
Taiwan
12
 
 
 
 
Thailand
13
 
 
 
 
United Kingdom
14
 
 
 
 
United States
15
 
 
 
 
_______________
16
 
 
 
 
_______________
17
 
 
 
 
_______________
18
 
 
 
 
_______________
19
 
 
 
 
_______________
20
 
 
 
 
_______________
21
 
 
 
 
_______________
22
 
 
 
 
_______________
23
 
 
 
 
Others
24
 
 
 
 
Total
25
 
 
 
 
 
 
 
 
 
Instructions for completion of Annex 2 to Form I
      An exempt insurance broker shall complete separate forms for each type of registration.
PART A :   SOURCE OF BUSINESS
1. The classification of territory shall be by country of domicile of reinsureds.
2.For those countries which are not listed under Rows 1 to 9 and the reinsurance premiums sourced from each country amounts to —
(a)5% or more of total premiums for Offshore Risks, please list down the countries under Rows 10 to 16 and specify the amount of premiums sourced from each country; or
(b)less than 5% of total premiums for Offshore Risks, please provide the aggregate premiums sourced from all these countries under Row 17.
PART B:   PLACEMENT OF BUSINESS WITH INSURERS OUTSIDE SINGAPORE (EXCLUDING FOREIGN INSURERS UNDER THE FOREIGN INSURERS SCHEME AND PROTECTION AND INDEMNITY CLUBS)
1.For those countries which are not listed under Rows 1 to 15 and the reinsurance premiums placed with each country amounts to —
(a)5% or more of total premiums for Domestic Risks or Offshore Risks, as the case may be, please list down the countries under Rows 16 to 23 and specify the amount of premiums for Domestic Risks or Offshore Risks, as the case may be, placed with each country; or
(b)less than 5% of total premiums for Domestic Risks or Offshore Risks, as the case may be, please provide the aggregate premiums for Domestic Risks or Offshore Risks, as the case may be, placed with all these countries under Row 24.
 
Regulation 12
 
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM J
 
CERTIFICATE ON THE ACCOUNTS OF
THE INSURANCE BROKING BUSINESS OF ______________
FOR THE FINANCIAL YEAR ENDED ____________________
 
      We, the undersigned, hereby certify that in our belief the assets set forth in the balance-sheet in Form A are fully of the value stated in the balance-sheet, and that in the relevant financial year, regulations 3 (3) and 4 (3) of the Insurance (Intermediaries) Regulations 2003 have been complied with; and that no part of the assets has been dealt with in contravention of section 35ZC or 35ZD of the Insurance Act (Cap. 142); except
Names and signatures of:
__________
Director
__________
Director
________________
Chief Executive Officer
 
Date: ________________
 
Regulation 13
INSURANCE ACT
(CHAPTER 142)
 
INSURANCE
(INTERMEDIARIES)
REGULATIONS
 
FORM K
 
REPORT OF THE AUDITORS APPOINTED UNDER
SECTION 36 OF THE INSURANCE ACT TO
AUDIT THE ACCOUNTS OF THE INSURANCE BROKING BUSINESS
OF _______________________________
FOR THE FINANCIAL YEAR __________ TO ___________
1.We have examined the attached balance-sheet as at _________________, insurance broking premium accounts, profit and loss account and other statutory returns for the financial year.
2.Our audit was carried out in accordance with the requirements of section 36 of the Insurance Act (Cap. 142), for the purpose of expressing our opinion on the accounts drawn up in accordance with the provisions of the Insurance Act. Our examination was necessarily conducted on a test basis and included such samples as we deemed appropriate. In this connection, we have reviewed the accounting system and system of internal controls in operation and reliance has been placed on internal controls where appropriate.
3.In our opinion and to the best of the information and according to the explanations given to us —
(a)the balance-sheet, insurance broking premium accounts, profit and loss account and other statutory returns have been prepared in accordance with the provisions of the Insurance Act and any regulations made thereunder;
(b)the balance-sheet represents a true and fair view of the financial position of the business of the registered insurance broker; and
(c)the books of the registered insurance broker have been properly kept and recorded fairly the affairs and transactions of the insurance broker in respect of that business.
4.As far as can be ascertained from our examination, in our opinion —
(a)the appropriate professional indemnity insurance required under section 35Y (1) (c) of the Insurance Act is in force;
(b)the prescribed net asset value required under section 35ZC of the Insurance Act has been complied with; and
(c)the insurance broking premium accounts have been established and maintained in accordance with section 35ZD of the Insurance Act; except
_____________________________(Firm)
Public Accountants and Chartered Accountants
Singapore
Date: ___________________
 
[S 832/2013 wef 31/12/2013]
[S 747/2007 wef 01/01/2008]