FORM IC-P01

Application for approval from the Insurance Authority (“Authority”) or Written Return to inform the Authority in respect of an individual who is proposed to be or has been appointed as a controller (other than a controller within the meaning of section 9(1)(a)(iii)(B) of the Insurance Ordinance (Cap. 41) (“Ordinance”)), director, key person in control functions or an authorized representative of Lloyd’s

or

Written return to inform the Authority in respect of change in the particulars of an individual who has been appointed as a controller (other than a controller within the meaning of section 9(1)(a)(iii)(B) of the Ordinance), director, key person in control functions or an authorized representative of Lloyd’s

1. Please respond to the following items (a) to (d) and then click “GO”. Then the purpose of submission of this form and the required item numbers will be displayed.

(a) Type of insurer:
(b) Type of business operation:
(c) Position:
(d) Type of submission:
Case reference (please also refer to summary table)
Sub-case reference (please also refer to summary table)
Purpose of submission of this form
Required items

2.

Name of authorized insurer/insurer:	Click or tap here to enter text.
☐ Lloyd’s
Unique business identifier of the authorized insurer/insurer:	Click or tap here to enter text.
Date of appointment of the individual:	Day (dd)	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.

3. Information of the individual to whom this form applies

Salutation:	Choose an item. ☐Other salutation: Click or tap here to enter text.
First Name and Middle Name2 :	Click or tap here to enter text.
Family Name:	Click or tap here to enter text.
Any other name(s) by which you have been known or are known:	Click or tap here to enter text.
Hong Kong Identity Card Number or Passport Number:	☐ Hong Kong Identity Card Number ☐ Passport Number (not a holder of Hong Kong Identity Card)
Click or tap here to enter text.
Nationality:	Click or tap here to enter text.
Acquired Choose an item.
Date of birth:	Date (dd)	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
Place of birth:	Jurisdiction	Town or city
Click or tap here to enter text.	Click or tap here to enter text.
Place of residence in the last 10 years:	Jurisdiction	From	To
Month (mmm)	Year (yyyy)	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.

4. Other information of the individual:

Residential address:	Click or tap here to enter text.
Phone number:	Office number
Country code	Number
Click or tap here to enter text.	Click or tap here to enter text.
Mobile number
Country code	Number
Click or tap here to enter text.	Click or tap here to enter text.
Business email address (if nil, then private email address):	Click or tap here to enter text.

5. Details of educational qualifications and professional qualifications possessed, including those relating to insurance and allied matters.

(Please start with the most recent entry)

(a) Details of educational qualifications possessed:
University attended:	Degree level:	Programme:	Date of award:	Other details, optional (e.g. major or minor):
Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.	Click or tap here to enter text.
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.	Click or tap here to enter text.
(b) Details of professional qualifications possessed which are currently valid.
Name of institution:	Professional qualifications:	Membership number, if available:	Date of Qualification:
Month (mmm)	Year (yyyy)
☐ Hong Kong Institute of Certified Public Accountants	☐ Certified Public Accountant (CPA)	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
☐ CFA Institute	☐ Chartered Financial Analyst (CFA)	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
☐ Global Association of Risk Professionals	☐ Financial Risk Manager (FRM)	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
☐ Chartered Insurance Institute (CII)	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
☐ The Australian and New Zealand Institute of Insurance and Finance (ANZIIF)	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
☐ Association of Certified Anti-Money Laundering Specialists	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
☐ Institute and Faculty of Actuaries of the United Kingdom	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
☐ The Institute of Actuaries of Australia	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
☐ Society of Actuaries of the United States of America	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
☐ Casualty Actuarial Society of the United States of America	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
☐ The Actuarial Society of Hong Kong	Choose an item.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.

6. Occupations and employment in all types of business (i.e. not limited to insurance or related business) during the last 10 years, including the name of the employer / principal, the nature of the business, the position held and relevant dates.

(Please provide details from the most recent entry)

Full name of the employer / principal:	Nature of the employer / principal’s business:	Position held:	Details of experience (Description of Duties) :	Relevant dates:
From	To (Please fill in the month and year below for past occupation or employment)
Month (mmm)	Year (yyyy)	Current	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.	☐	Choose an item.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.	☐	Choose an item.	Click or tap here to enter text.
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.	☐	Choose an item.	Click or tap here to enter text.

7. Relevant experience (other than occupation or employment in question 6 above) (if any):

Click or tap here to enter text.

8. Specify the kind of control functions (within the meaning of section 13AE(12) of the Ordinance) that you will be responsible for. Will you be solely responsible or jointly responsible for the control functions? For the latter case, provide particulars (including name, role and position) of the other key person(s) and describe in detail how you will be jointly responsible for the control functions. (Note: Separate form is required for each key person in control functions being jointly responsible for the same control function.)

☐ I will be solely responsible for Choose an item..
☐ I will be jointly responsible for Choose an item. with: Name of the other key person: Click or tap here to enter text. Position of the other key person: Click or tap here to enter text. Describe in detail how you will be jointly responsible for the control functions: Click or tap here to enter text.

9. To whom are you reporting? Describe the reporting structure or reporting lines that you have in relation to the person(s) within the insurer, at the head office of the insurer, and at the holding company of the insurer, as may be appropriate. Provide an organizational chart showing your position in the management and governance structure, business and operational units of the insurer and your respective reporting lines.

Current reporting structure or reporting lines:
Click or tap here to enter text.
Organizational chart:
Click or tap here to enter text.

10.

(a) Have you been convicted of any criminal offence (other than an offence committed more than 10 years ago when you were of or under the age of 16 years) by any court, including a military tribunal, in Hong Kong or elsewhere?	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(b) Are you the subject of unresolved criminal charges in Hong Kong or elsewhere?	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(c) Have you contravened or abetted another person in breach of any laws11, regulations or codes of conduct (other than a contravention or abetment of more than 10 years ago when you were of or under the age of 16 years) in Hong Kong or elsewhere in relation to business previously or currently carried on?	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(d) Have you been found by a court or other competent authority in Hong Kong or elsewhere for fraud, dishonesty or misfeasance?	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(e) Have you been disqualified by a court of competent jurisdiction from being a director of a body corporate?	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

11.	Have you, in the last 10 years, in Hong Kong or elsewhere—

(a) been refused or restricted from the right to carry on any trade, business or profession by any regulatory authority; or	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(b) been censured, disciplined or publicly criticized by any regulatory authority; or	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(c) been the subject of an investigation or disciplinary proceedings by any regulatory authority or law enforcement agency; or	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(d) been the subject of any substantiated complaint made reasonably and in good faith, relating to activities that are regulated by any regulatory authority; or	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(e) been untruthful to, provided false or misleading information to, or been subject to adverse comment from, any regulatory authority?	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

12. Have you, in the last 10 years, in Hong Kong or elsewhere—

(a) been censured, disciplined or publicly criticized by a professional body to which you belong or belonged; or	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(b) been the subject of an investigation or disciplinary proceedings by a professional body to which you belong or belonged; or	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(c) failed to uphold any professional and ethical standards of a professional body to which you belong or belonged; or	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.
(d) been refused entry to any profession or occupation?	Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

13. Have you, in the last 10 years, in Hong Kong or elsewhere, been dismissed or requested to resign from any office, employment or a fiduciary appointment or similar position for misconduct, negligence, incompetence or mismanagement?

Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

14. Have you entered into a voluntary arrangement with creditors or been adjudicated bankrupt by a court, or are you currently subject to bankruptcy proceedings, in Hong Kong or elsewhere?

Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

15. Have you, in the last 10 years, failed to satisfy any debt adjudged due and payable by you as a judgment-debt or under an order of a court in Hong Kong or elsewhere?

Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

16. Have you, in connection with the formation or management of a body corporate or an insurer, been adjudged by a court or other competent authority in Hong Kong or elsewhere civilly liable for any fraud, misfeasance or other misconduct by you towards the body or insurer or towards any members of the body or insurer?

Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

17. Has any body corporate or insurer with which you were associated as director, controller (within the meaning of section 9 of the Ordinance), shareholder controller (within the meaning of section 2 of the Ordinance), key person in control functions or actuary appointed under the Ordinance (including under section 15AAA or section 15 prior to the full commencement of the Insurance (Amendment) Ordinance 2023) in the last 10 years, in Hong Kong or elsewhere, been compulsorily wound up or made any compromise or arrangement with its creditors or ceased trading in circumstances where its creditors did not receive or have not yet received full settlement of their claims, either while you were associated with it or within one year after you ceased to be associated with it?

Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

18.	Have you been, in connection with the management of a body corporate or an insurer in Hong Kong or elsewhere, a controller, shareholder controller, director, key person in control functions or actuary appointed under the Ordinance12, of the body corporate or insurer, which-

with the consent or connivance of, or because of the neglect or omission by you, failed to comply with any legal or regulatory requirements or any regulatory instruments made thereunder;

was or has been convicted of a criminal offence by any court, or is the subject of unresolved criminal charges, in Hong Kong or elsewhere; or

was or has been adjudicated by any court or other competent authority civilly liable for any fraud, misfeasance or misconduct, in Hong Kong or elsewhere?

Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

19.	Of what bodies corporate or insurers you are now, or you have been during the last 10 years, a director, controller (within the meaning of section 9 of the Ordinance), shareholder controller (within the meaning of section 2 of the Ordinance) or a key person in control functions (within the meaning of section 13AE(12) of the Ordinance)12?

(Please provide details from the most recent entry)

Name of body corporate / insurer:	Capacity:	(For key person in control functions) Control function:	Relevant dates:
From:	To (Please fill in the month and year below for past appointments):
Month (mmm)	Year (yyyy)	Current	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Choose an item.	Choose an item.	Click or tap here to enter text.	☐	Choose an item.	Click or tap here to enter text.
Click or tap here to enter text.	Choose an item.	Choose an item.	Choose an item.	Click or tap here to enter text.	☐	Choose an item.	Click or tap here to enter text.
Click or tap here to enter text.	Choose an item.	Choose an item.	Choose an item.	Click or tap here to enter text.	☐	Choose an item.	Click or tap here to enter text.

20. In carrying out your duties for the insurer, will you be acting on the directions or instructions of any person?

Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

21. Any additional information that you consider to be relevant or material to this application or notification.

Click or tap here to enter text.

Declaration by the individual

☐ I certify that the above information is complete and correct to the best of my knowledge and belief.
☐ I certify that this Form is served with the knowledge and consent of me.
☐ I certify that upon appointment as a director of the insurer, I will become an independent non-executive director (INED) satisfying criteria of independence in the Guideline on the Corporate Governance of Authorized Insurers (GL10).
Signed (Individual named in item 3 above):
Date:	Click or tap to enter a date.

Declaration by the authorized insurer/insurer

I certify that —
☐the individual to whom particulars relate has supplied the above information and that in respect of the authorized insurer/insurer the individual is proposed to be appointed as Choose an item. .
☐the individual to whom particulars relate has supplied the above information and that in respect of the authorized insurer/insurer the individual is Choose an item. .
☐the above information is complete and correct to the best of my knowledge and belief.
Signed:
☐ Choose an item.of the Authorized Insurer/Insurer ☐ Choose an item. of Lloyd’s
Name of the signatory:	Click or tap here to enter text.
Date:	Click or tap to enter a date.

(for case (A) or (B)) Please submit the following together with the form:

☐ a certified true copy of the Hong Kong Identity Card or Passport indicated in item 4;

☐ a certified true copy of certificate or alternative supporting documents of education qualifications indicated in item 5;

☐ a certified true copy of proof of current membership for professional qualifications indicated in item 5;

☐ if any of the answer in items [10] to [18] is yes, relevant documents that provides details in respect of the particulars given above.

Copies may be certified by:

a certified public accountant (practising), solicitor, notary public, court officer or professional company secretary, in Hong Kong or the equivalent profession or position in a place outside Hong Kong; or

a director, company secretary or section 13A controller of the authorized insurer/insurer.

Note for completing the form:

In relation to a body corporate which is not an insurer, “controller” (控權人) is to be construed as a reference to a person who would, if the person were a company, be a holding company of that body in accordance with section 13 of the Companies Ordinance (Cap. 622)

For changes in particulars within the scope as indicated that take place on or after 01 Jul 2024, it is required to be updated to the IA using this form.

Authorization by the individual

☐ I authorize any local or overseas regulatory, government or judicial bodies / industry bodies / professional bodies / courts, tribunals and committees, their respective representatives, or such relevant organizations / persons, to release to the Insurance Authority full particulars of any pertinent information and materials relating to me, including but not limited to my character, education, qualifications, work experience, criminal conviction records (if any), all other legal and regulatory proceedings/investigations/disciplinary actions recorded against me (whereby I was found guilty or liable to) or all ongoing investigation/regulatory/criminal proceedings to which I have been subject to, as the Insurance Authority may from time to time request you to provide for vetting purposes.
☐ I agree that a photocopy of this authorization shall be as valid as the original.
☐ I confirm that I have read and understood the enclosed Personal Information Collection Statement.
☐ I consent to the Insurance Authority using any personal information I have provided in the relevant application or any associated documentation or any personal information I may provide in the future, for the purposes described in the Personal Information Collection Statement.
☐ I understand that the Insurance Authority may make such enquiries and seek such further information from time to time as it considers appropriate.
Signed:
Name of the signatory:	Click or tap here to enter text.
Date:	Click or tap to enter a date.

Insurance Authority (“Authority”)

Personal Information Collection Statement (“PICS”)

This PICS is made by the Authority to comply with the notification requirements of the Personal Data (Privacy) Ordinance (Cap. 486) (the “PDPO”). You are advised to read it carefully as it sets out the policies and practices of the Authority in relation to your personal data (as defined in the PDPO), the purposes for which the Authority may collect and use your personal data and the persons to whom your personal data may be transferred.

Purpose of Collection

Your personal data provided in (and in support of or in connection to) the form by you or any other persons may be used and held by the Authority for one or more of the following purposes:

to administer and/or enforce the provisions of any relevant ordinances (including the Insurance Ordinance (Cap. 41) (the “Ordinance”)) and any regulations, rules, codes guidelines, circulars or other regulatory instruments made or promulgated pursuant to the powers vested in the Authority as in force at the relevant time and to carry out its functions as a regulator of the insurance industry, including:

to process any application made to or received by the Authority under the Ordinance;

to assess your fitness and propriety in relation to any application or approval under the Ordinance;

to assess and monitor your fitness and propriety and your status for appointment or to remain to be appointed as controllers, shareholder controllers, directors, key persons in control functions and/or actuaries appointed (as the case may be) under the Ordinance;

to consider any application under the Ordinance where you may otherwise have a connection;

to investigate complaints and handle enquiries;

to conduct legal proceedings, inspection, investigation and/or other enforcement/disciplinary actions;

to co-operate with and assist other regulatory body and/or law enforcement body of Hong Kong or of any place outside Hong Kong, whenever appropriate, to the extent permitted by the laws of Hong Kong;

for any statistical and research purposes; and/or

any other purposes as permitted by the laws of Hong Kong.

You are obliged to supply the requested personal data where a specified requirement has been imposed upon you under the laws and regulations (including the Ordinance) or in response to any request from the Authority in exercising its powers or carrying out its functions. Failure to provide the requested personal data may result in the Authority being unable to exercise its powers or carrying out its functions under the Ordinance and/or other relevant laws and may affect the Authority’s assessment of your fitness and propriety under the Ordinance.

Transfer/Matching of Personal Data

In performing the Authority’s functions under the relevant laws and regulations, your personal data held by the Authority may, for the aforesaid purposes, be disclosed or transferred to any third parties, including financial regulators in Hong Kong (including but not limited to the Mandatory Provident Fund Schemes Authority, the Securities and Futures Commission and the Hong Kong Monetary Authority), educational institutions / examination bodies in or outside Hong Kong (e.g. for the purposes of verifying academic / professional qualifications), the relevant industry bodies (e.g. the Insurance Complaints Bureau, the Hong Kong Federation of Insurers, the Hong Kong Confederation of Insurance Brokers and the Professional Insurance Brokers Association), the relevant professional bodies (e.g. the Law Society of Hong Kong, the Hong Kong Bar Association, the Actuarial Society of Hong Kong and the Hong Kong Institute of Certified Public Accountants), law enforcement agencies, the relevant courts, tribunals and committees and/or other local and/or overseas regulatory/government/judicial bodies as permitted or required under the laws of Hong Kong, pursuant to any regulatory/supervisory/investigatory assistance arrangements between the Authority and such regulators/bodies (within or outside Hong Kong), or persons engaged by the Authority to assist it in the performance of its statutory functions.

Personal data may be used by the Authority and/or disclosed or transferred by the Authority to the above parties for the purposes of comparing, verifying and/or carrying out a matching procedure of those data.

Access to Data

Under the PDPO, you have the right to request access to, and to request the correction of, your personal data held by the Authority. If you wish to request access to or correction of your personal data held by the Authority, you may do so by filling in a “Data Access Request Form” and sending it by post to the Data Privacy Officer of the Authority at 19/F., 41 Heung Yip Road, Wong Chuk Hang, Hong Kong. The Authority has the right to charge a reasonable fee for processing such request.

Enquiries

Any enquiries regarding the personal data collected, used or transferred by the Authority or requests for access to personal data or correction of personal data should be addressed in writing to the Data Privacy Officer of the Authority at the above address.

A copy of the Authority’s Privacy Policy is made available at the Authority’s website: www.ia.org.hk

JUL 2024

Applicable to case (B) only

The name as shown in your Hong Kong Identity Card or, for an individual not being a holder of Hong Kong Identity Card, the name as shown in your Passport.

Not applicable to case (C)

Not applicable to case (C)

Not applicable to case (C)

Including sole proprietorship, partnership, advisor, consultant, agent or any other position performing job or work duties, whether remunerated or not.

Not applicable to case (C)

Applicable to application or written return in relation to key person in control functions only

The name as shown in the person’s Hong Kong Identity Card or, for an individual not being a holder of Hong Kong Identity Card, the name as shown in the person’s Passport.

Not applicable to case (C)

Other than minor offence, meaning an offence punishable by a fixed penalty under the Fixed Penalty (Traffic Contraventions) Ordinance (Cap. 237), the Fixed Penalty (Criminal Proceedings) Ordinance (Cap. 240), the Fixed Penalty (Public Cleanliness and Obstruction) Ordinance (Cap. 570), the Fixed Penalty (Smoking Offences) Ordinance (Cap. 600) or the Motor Vehicle Idling (Fixed Penalty) Ordinance (Cap. 611), or an offence of similar nature committed in a place outside Hong Kong.

Only director and controller are in relation to a body corporate. All positions are in relation to an insurer.

Applicable to case (A) or (B)

Applicable to application for approval of a proposed appointment of an INED of an HK insurer or a designated insurer

Applicable to case (A)

Applicable to case (B)

Applicable to case (C)

Section 13A controller of the Authorized Insurer/Insurer is only applicable to case (C)

Applicable to case (A) or (B)

“matching procedure” is defined in section 2 of the PDPO.

A copy of the Data Access Request Form is available at: http://www.pcpd.org.hk/english/resources_centre/publications/forms/files/Dforme.pdf