Written return to inform the Insurance Authority (“Authority”) in respect of a person becoming a controller within the meaning of section 13A(12) of the Insurance Ordinance (Cap. 41) (“Ordinance”), shareholder controller pursuant to section 13B(2) or (2A) of the Ordinance, director pursuant to section 13AC(1) of the Ordinance, key person in control functions within the meaning of section 13AE(12) of the Ordinance pursuant to section 13AE(1) of the Ordinance or an authorized representative of Lloyd’s pursuant to section 50B of the Ordinance

or

Written return to inform the Authority in respect of a person ceasing to be a controller within the meaning of section 9 of the Ordinance, shareholder controller within the meaning of section 2(1) of the Ordinance, director, key person in control functions within the meaning of section 13AE(12) of the Ordinance 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)
Purpose of submission of this form
Required items

2.

Name of authorized insurer:	Click or tap here to enter text.
☐ Lloyd’s
Unique business identifier of the authorized insurer:	Click or tap here to enter text.

3.

Name of the individual/body corporate in English:	Click or tap here to enter text.
Name of the individual1/body corporate in Chinese (if any):	Click or tap here to enter text.
(For individual) 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.
(For body corporate) Unique business identifier (if any):	Click or tap here to enter text.

4.

Date on which the person became/ceased to be Choose an item.:	Day (dd)	Month (mmm)	Year (yyyy)
Click or tap here to enter text.	Choose an item.	Click or tap here to enter text.

5. Confirmation that the subject person has become—

☐ a controller within the meaning of section 13A(12) of the Ordinance
☐ a shareholder controller pursuant to section 13B(2) or (2A) of the Ordinance
☐ a director pursuant to section 13AC(1) of the Ordinance
☐ a key person in control functions (within the meaning of section 13AE(12) of the Ordinance) pursuant to section 13AE(1) of the Ordinance
☐ an authorized representative of Lloyd’s pursuant to section 50B of the Ordinance

and that there has not been any change to the information and particulars provided in the concerned application for approval submitted to the IA in respect of that person’s proposed appointment pursuant to section 13A(2), 13AC(2), 13AE(2), 13B(2) or (2A), and/or 50B of the Ordinance (as the case may be).

6.

Reason for ceasing to be a controller (within the meaning of section 9 of the Ordinance), shareholder controller (within the meaning of section 2(1) of the Ordinance), director, key person in control functions (within the meaning of section 13AE(12) of the Ordinance) or an authorized representative of Lloyd’s (as the case may be)—
Click or tap here to enter text.

Signed:
Name of the signatory:	Click or tap here to enter text.
Position:	☐ Choose an item. of the authorized insurer ☐ Choose an item. of Lloyd’s
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), 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

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.

Applicable to case (A)

Applicable to case (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