‘THE HONG KONG FEDERATION OF INSURERS ‘Subscription Declaration Form General Insurance Member PLEASE COMPLETE AND RETURN THIS FORM TOGETHER WITH PAYMENT TO THE FEDERATION BY 34 DECEMBER 2023. You are requested to indicate below your Company's 2024 subscription fee according to your company's {gross written premium income based on your latest audited accounts. Where the financial year is less than ‘12 months, the premium income should be grossed up to a 12 month period pro rata, Premium income includes individual and group business through regular and single premium writen directly cr indirectly and generated from Hong Kong activities, Gross written premium Please Income based on Ticky Latest audited accounts: ‘Subscriptions ($) No Hong Kong Business 14,740, v O>$25m_ 28,100 [LE] s25m>ssom 38,180 C] $50m>$100m 51,540, [LE] stoomstsom 61,590 [5] st50m>s250m 74,980 [7] __ s250m=sasom 88,380 [1 __ s350m=ssoom 401,780 [1 s500m=s7s0m 116,160 [LE] 8760m>s1,000m 428,560 [1] s1,000m=$1,500m 185,330 E1__ 51.500m=>$2,000m 482,130 oO Exceeding $2,000m 208,900 Declaration | hereby dectare that the gross writen premium income of my company based on our latest audited accounts is in the range indicated above, which is consistent with the 2022 fiqure | have reported to the Insurance Authority. As such, my company subscription is §_Please select Enclosed please find a crossed cheque/payment advice for this amount made payable to “The Hong Kong Federation of Insurers". We understand that our paid subscriotion is non-refudable. FIRST AMERICAN TITLE INSURANCE CO. Company Name Signature of Authorized Representative Name PHILIP WALDEN pate 19/12/2023 tte CHIEF EXECUTIVE (auserstanitaieutizdgeub doc)