Name of authorised insurance company in respect of which the notification is being given.

The proposed or assumed position to which the notification relates.

If the proposed position is that of controller, the provision of section 96C of the Act by virtue of which the individual serving notice would become a controller.

Full name (which shall be given in the order surname/forenames and including title and any name by which commonly known).

Any previous names by which known (including name before marriage).

Any trading names used as a sole trader in the last ten years.

Date of birth (which shall be given in the order day/month/year).

Place of birth (including town and where appropriate the London borough).

Private address or addresses.

If other than the particulars specified in response to C6 above, the address or addresses of any residence outside the United Kingdom in the last five years and the dates of such residence.

Nationality, including a statement as to whether it was acquired by birth or naturalisation, and if by naturalisation a statement when so acquired. In the case of dual nationality, the details of each nationality.

Relevant United Kingdom and overseas qualifications.

Details of all employment or occupation over the last ten years, including names and addresses of employers, dates of employment or occupation (months and years), positions held, summary of responsibilities and reasons for leaving. Any intervals between employment or occupation shall be explained.

Details of all directorships currently held.

Details of all other directorships held during the last ten years.

Details of all bodies corporate in which the individual or a partnership in which the individual is a partner is entitled to exercise, or control the exercise of, 10 per cent. or more of the voting power at any general meeting, together with a brief description of his activities.

Details of any authority (as defined) held from any supervisory body as an individual to carry on business.

Details of any draft or formal application made for an authority from a supervisory body to carry on business other than an authority already mentioned in response to F1 above. If any application was, for any reason, refused or withdrawn, particulars of the refusal or withdrawal.

Details of any conviction for any offence involving fraud or other dishonesty or under legislation relating to companies, building societies, industrial and provident societies, credit unions, friendly societies, insurance, banking or other financial services, consumer credit or consumer protection. Details shall include the court where the conviction took place, the offence, the penalty imposed and the date of the conviction. By virtue of article 3(a)(iii) of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 197548, spent convictions shall be disclosed.

Details of other convictions, including full particulars of the court where the conviction took place, the offence, the penalty imposed and the date of the conviction.

* Details of any case of failure to satisfy a judgment debt under a court order within a year of the making of the order.

* Details of any compromise or arrangement with creditors or other failure to satisfy creditors in full.

* Details of the presentation of any petition for the bankruptcy of the individual and the appointment of any receiver, or any administrator of the individual’s estate or of any person performing a similar function.

* Details of the winding up of any company, or the subsidiary of any company, of which the individual is or was a controller within 5 years of the commencement of the winding up.

Details of any adjudication by a court making the individual liable for any fraud, misfeasance or wrongful trading or other misconduct in respect of the formation or management of any company, partnership or unincorporated association.

Details of any dismissal from any office or employment or from any fiduciary office or position of trust whether or not remunerated (unless already notified in response to D2 above).

* Details of any refusal of entry to any professional body or trade association or any case where an application was not made following an initial approach to any professional association or trade association.

* Details of any disqualification by a court from acting as a director or being concerned in the management of a company.

* Details of any case of warning, censure, prosecution, criticism or court order made at the instigation of any regulatory body.