Application for approval from the Insurance Authority (“Authority”) in respect of a body corporate which is proposed to become a shareholder controller pursuant to section 13B(2) or (2A) of the Insurance Ordinance (Cap. 41) (“Ordinance”) or has become a shareholder controller in contravention of section 13B(2) or (2A) of the Ordinance

or

Application for approval from the Authority in respect of a body corporate which is proposed to be appointed as a director pursuant to section 13AC(2) of the Ordinance

or

Written return to inform the Authority in respect of a body corporate which has become a controller within the meaning of section 9 of the Ordinance or a director

or

Written return to inform the Authority in respect of change in the particulars of a body corporate which is a shareholder controller within the meaning of section 2(1) of the Ordinance, a controller within the meaning of section 9 of the Ordinance or a director

or

Written return to inform the Authority in respect of a body corporate who has ceased to be a majority shareholder controller and become a minority shareholder controller pursuant to section 13B(2)(b) of the Ordinance

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

(a) Type of business operation:
(b) Position:
(c) 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.
Unique business identifier of the authorized insurer/insurer:	Click or tap here to enter text.
For case (B), (D), (E) or (F): Date on which the body corporate became such a shareholder controller, controller or director (as the case may be) For case (G): Date on which the body corporate became a minority shareholder controller	Day (dd)	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
For case (A): Proposed percentage of voting power at a general meeting of the insurer the body corporate is entitled to exercise or has control to exercise For case (B), (D1), (E1), (F1), (F2), (F3) or (G): Existing percentage of voting power at a general meeting of the insurer the body corporate is entitled to exercise or has control to exercise	For case (A), (B), (D1), (E1) or (G), please state the proposed / exact percentage: Click or tap here to enter text.% For case (F1), (F2) or (F3), please check one of the boxes below: ☐ Less than 15% ☐ 15% or more but less than 25% ☐ 25% or more but less than 50% ☐ 50% or more but less than 75% ☐ 75% or more

3. Information of the body corporate:

Name of the body corporate in English:	Click or tap here to enter text.
Name of the body corporate in Chinese (if any):	Click or tap here to enter text.
Principal business activity:	Click or tap here to enter text.
Date of incorporation:	Day (dd)	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
Place of incorporation:	Click or tap here to enter text.
Date of re-domiciliation (if applicable):	Day (dd)	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
Place of domicile (if applicable):	Click or tap here to enter text.
(If the body corporate, or a company within the same group of companies to which the body corporate belongs to, is listed on a stock exchange in Hong Kong or elsewhere):	Name of the listed company:
Click or tap here to enter text.
Date of listing:
Day (dd)	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.
Name of the stock exchange:
Click or tap here to enter text.
Unique business identifier (for body corporate registered in Hong Kong):	Click or tap here to enter text.
If the body corporate is not registered in Hong Kong, provide any business registration number registered in the place of incorporation or domicile: Click or tap here to enter text.

4. Contact:

Address of registered office:	Click or tap here to enter text.
Address of principal place of business established in Hong Kong (if any):	Click or tap here to enter text.
Office telephone number:	Country code	Number
Click or tap here to enter text.	Click or tap here to enter text.
Email address:	Click or tap here to enter text.

5. Details of every director and every controller within the meaning of section 9 of the Ordinance.

Full name:	Director (other than INED)/ Independent Non-executive Directors / Controller:	For individuals	For body corporates
Identity document:	Hong Kong Identity Card Number or Passport Number:	Unique business identifier:
Click or tap here to enter text.	Choose an item.	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.	Choose an item.	Click or tap here to enter text.	Click or tap here to enter text.

6. Describe the corporate governance structure in place (including board membership, composition of board committee and proportion of directors being independent non-executive directors) of the body corporate. Attach corporate governance report if available. Please state any material deficiencies on internal controls and corporate governance identified by auditors, internal audit or senior management in the last 10 years, or those material deficiencies which rectification or remediation has not been fully completed or implemented.

Click or tap here to enter text.

7. Provide details on the existing measures, regulations or restrictions of the body corporate’s internal controls and corporate governance. Without prejudice to the generality of this question, please specify:

the internal control systems and procedures on the appointment of board members and senior management to act on its behalf, including the assessment of fitness and propriety and any measures, regulations or restrictions it is subject to.

details on the systems of risk management and internal controls for monitoring risks at entity level and at group-wide basis (where relevant).

details on internal controls for financial reporting or regulatory reporting (where relevant), and assessment on its effectiveness.

Click or tap here to enter text.

8. Name and address of main bank:

Name of main bank:	Click or tap here to enter text.
Address of main bank:	Click or tap here to enter text.

9. Attach financial statements for the last 3 completed financial years of the body corporate and particulars of any reports, resolutions and other notices issued to its shareholders during the last 4 years.

Click or tap here to enter text.

10. Attach a proposed shareholding chart or existing shareholding chart of the insurer (as the case may be), these chart(s) should show all the entities within the structure and include:

All entities in the group of companies of which the insurer is a member of

Associate and joint venture

Percentage of voting power at the general meeting and direct shareholding, and include relevant details if any of the voting power is exercised through an associate as defined in section 9(4) of the Ordinance

Click or tap here to enter text.

11.Apart from shareholding, does the body corporate have any other association or relationship with the subject insurer?

Click or tap here to enter text.

12. Name, place of incorporation and principal activities of all subsidiary companies and of any holding company or ultimate holding company.

(Note: Shares held by a nominee are to be treated as shares held by the nominee’s principal).

Name of company:	Place of incorporation:	Principal activities:
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.	Click or tap here to enter text.

13. In the case of a non-Hong Kong company as defined by section 2(1) of the Companies Ordinance (Cap. 622)—

(a) name(s) and address(es) of its authorized representative(s) as defined by section 774 of the Companies Ordinance (Cap. 622);
Name(s)	Click or tap here to enter text.
Address(es)	Click or tap here to enter text.
(b) date of the certificate of registration issued under Part XI of the Companies Ordinance (Cap. 32) as in force from time to time before 3 March 2014 or under section 777 of the Companies Ordinance (Cap. 622).
Day (dd)	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.

14. Has the above-named body corporate, 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 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.

15. Has the above-named body corporate, in the last 10 years, been subject to receivership, administration, liquidation or other similar proceedings?

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

16. Has the above-named body corporate, in the last 10 years, entered into a scheme of arrangement with its creditors or failed to satisfy any judgment debt 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.

17. Has any body corporate or insurer with which the above-named body corporate was associated as director, controller (within the meaning of section 9 of the Ordinance) or shareholder controller (within the meaning of section 2 of the Ordinance) 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 the above-named body corporate was associated with it or within one year after the above-named body corporate ceased to be associated with it?

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

18.	Has the above-named body corporate been, in connection with the management of a body corporate or an insurer in Hong Kong or elsewhere, a controller, shareholder controller or director, of the body corporate or insurer, which-

with the consent or connivance of, or because of the neglect or omission by the body corporate concerned, 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.

(a) If and after the proposed changes take place or the approval is given (as the case may be), how long do the body corporate intend to remain in the relevant position?
Click or tap here to enter text.
(b) Does the body corporate intend to reduce or increase the level of control in the foreseeable future?
Choose an item.
If yes, give full particulars:
Click or tap here to enter text.

The below items 20 to 22 are applicable to a prospective or existing majority shareholder controllers in case (A) or (B) or a controller which will become a majority shareholder controller of an HK insurer or a designated insurer in case (D1) immediately after the grant of authorization to the insurer.

20. Please submit strategic objectives and business plans and demonstrate such objectives and plans are realistic, viable and conducive to the long-term stability and healthy and sustainable development of the insurer.

Click or tap here to enter text.

21. Please provide information about the body corporate’s willingness and financial capacity to maintain the financial soundness of the insurer including to contribute additional capital to support the operations of the insurer, as and when needed. Please also explain the sources of additional capital.

Click or tap here to enter text.

22. Describe the intentions and expectations towards the insurer in the short, medium and long-term so as to demonstrate commitment to the development of the insurer, including but not limited to areas such as financial goals, strategic development, synergies, reallocation of resources, integration, etc.

Click or tap here to enter text.

23. Give particulars of circumstances by virtue of which the above-named body corporate became a—

(Applicable to case (B)) minority shareholder controller or majority shareholder controller within the meaning of section 2(1) of the Ordinance. (Applicable to case (D1), (D2), (E1) or (E2)) controller within the meaning of section 9 of the Ordinance.
Click or tap here to enter text.

24. Any additional information that you consider to be relevant or material to this application or notification, or supplementary information to any of the above answers to items 1 to 23.

Click or tap here to enter text.

Declaration by a director or company secretary of the body corporate

I certify that—
☐ the above information is complete and correct to the best of my knowledge and belief.
☐ this Form is served with the knowledge and consent of the above-named body corporate.
☐in respect of the authorized insurer, the above-named body corporate is proposing to become a minority shareholder controller pursuant to section 13B(2) or majority shareholder controller pursuant to section 13B(2A) of the Ordinance (as the case may be).
☐in respect of the authorized insurer, the above-named body corporate is proposing to become a director pursuant to section 13AC(2) of the Ordinance.
Signed:
Name of the signatory:	Click or tap here to enter text.
Position:	Choose an item. of the body corporate
Date:	Click or tap to enter a date.

Declaration by the authorized insurer/insurer

I certify that —
☐ the body corporate to whom particulars relate has supplied the above information and that in respect of the authorized insurer/insurer the body corporate is Choose an item.
☐ the above information is complete and correct to the best of my knowledge and belief.
Signed:
Name of the signatory:	Click or tap here to enter text.
Position:	Choose an item. of the authorized insurer/insurer
Date:	Click or tap to enter a date.

(for case (A), (B), (C), (D) or (E)) Please submit the following together with the form:

☐ if any of the answer in items 14 to 18 is yes, relevant documents that provides details in respect of the particulars given above.

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 1 July 2024, it is required to be updated to the Authority using this form.

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), 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 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 any 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

Not applicable to case (F)

If the body corporate is not registered in Hong Kong, provide any business registration number registered in the place of incorporation

Not applicable to case (F) or (G)

Applicable to case (A), (B), (D1) or (E1)

For the purpose of sub-paragraph b), associate has the meaning given by Hong Kong Accounting Standard 28 (HKAS 28)

For the purpose of sub-paragraph b), joint venture has the meaning given by Hong Kong Financial Reporting Standard 11 (HKFRS 11)

Applicable to case (A), (B), (D1), (E1), (F1), (F2) or (F3)

Applicable to case (A), (B), (D1) or (E1)

Short term: within 3 years

Medium term: within 5 years

Long term: 10 years or longer

Applicable to case (B), (D1), (D2), (E1) or (E2)

Applicable to case (A), (B), (C), (D), (E) or (G)

Applicable to case (A)

Applicable to case (C)

Applicable to case (C), (D), (E) or (F)

Applicable to case (F)

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

“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