Your Pension Plan …. Your Financial Future

Administrator Forms

"*" indicates required fields

Pursuant to Section 6(f) of the National Pension Scheme
(Occupational Pensions) Act 1998

PART I: DETAILS OF APPLICANT
(complete as appropriate)

Will the applicant be offering pension plans and other pension plan/retirement products?

PART II: OPERATIONS OF THE APPLICANT

Part III: INSURANCE COVER

Indicate below whether the Applicant has cover in respect of the following:
Limit Deductible
Errors & omissions
Directors and officers liabilities
Fidelity and forgery
Loss of property
Computer crime
Computer damage
Business interruption
Office contents
Political risk
Other insurance (please provide details)
Has any application for insurance by the applicant or any predecessors in business ever been refused?
Have any material insurance claims been made by the applicant or any predecessors in business?

PART IV: PRIOR ISSUES

If the answer to any of the questions below is yes, please give full particulars in the space provided at the back of this questionnaire clearly stating to which question the details relate.
(a) Has the applicant ever applied for and been refused a licence or an equivalent authorisation or registration to conduct any financial services business in Bermuda or elsewhere?*
(b) Has the applicant failed to satisfy a judgement debt under a court order in Bermuda or elsewhere within a year of the making of the order?*
(c) Has the applicant made any compromise or arrangement with its creditors or otherwise failed to satisfy creditors in full?*
(d) Has the applicant ever had a receiver appointed over any of its property in Bermuda, or has the substantial equivalent of any such person been appointed in any other jurisdiction? If so, give full particulars.*
(e) Has the applicant ever had a petition for an administration order or the substantial equivalent of such a petition served on it in any jurisdiction?*
(f) Has the applicant ever had a notice of resolution for liquidation in Bermuda, or had the substantial equivalent of such a notice given in any other jurisdiction?*
(g) Has a petition ever been served in Bermuda for the compulsory liquidation of the applicant or any member of a group of which the applicant is a member or has the substantial equivalent of such a petition ever been served in any other jurisdiction?*
(h) Has an inspector or other authorised officer of any government department or agency, professional association or other regulatory body appointed under any Bermuda law (e.g. the Companies Act 1981) or equivalent overseas enactment, ever investigated the affairs of the applicant or any member of a group of which the applicant is a member?*
(i) Has the applicant or any member of a group of which the applicant is a member been required to produce books or records pursuant to section 110 of the Companies Act 1981 or similar provisions of regulatory legislation (e.g. within Bermuda or elsewhere?*
(j) Has the applicant or any member of a group of which the applicant is a member ever been censured, prosecuted, or warned as to future conduct, or disciplined or publicly criticized by, or made the subject of a court order at the instigation of any supervisory or regulatory authority?*
(k) Has the applicant or any member of a group of which the applicant is a member ever been refused entry in Bermuda or elsewhere to any professional body, stock exchange or trade association concerned with financial services?*
(l) Is the applicant or any member of a group of which the applicant is a member engaged or does it expect to be engaged in Bermuda or elsewhere in any litigation which may have a material effect on the resources of the undertaking?*

DECLARATION

This declaration must be completed by an authorized signing officer of the applicant in block capitals or typed.
confirm that I have read and understand the provisions of the National Pension Scheme (Occupational Pensions) Act 1998 (“the Act”) and I declare that the business in respect of which this application is made will be conducted in accordance with the provisions of the Act, the Regulations and any Codes of Conduct.
I declare that the particulars supplied in the application are true to the best of my knowledge and belief.
DD dash MM dash YYYY

Wessex House, 45 Reid Street, Hamilton

Tel. 441-295-8672

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