FORM 18

INSURANCE ACT, 1987

INSURANCE REGULATION, 1989 (Section 18)
____________________________________
APLICATION FOR ISSUE / RENEWAL* OF AN INSURANCE AGENT
(GENERAL) LICENCE
To:

The Commissioner of Insurance,

Individual applicant: Surname..................................................................................(Mr./Mrs/ Miss)*
First Names.............................................................................
OR
Business applicant:
Name or style under which business is to be conducted..............................................................
................................................................................................................................................................
Postal address .........................................................................................................................................
Residential address.................................................................................................................................
Business address....................................................................................................................................
Full name of insurer...............................................................................................................................
(A separate application is required in respect of each registered insurer to be represented).
Date on which licence is required to commence....................................................................................

I have not previously held an insurance agent (general ) license.

I undertake to advise the Commissioner of Insurance within (14) fourteen days if I cease to represent the
Above named registered insurer or I change the name under which I conduct my business, or if I change
My business.
........................................
Date

(Signed).............................................................
Signature of applicant