Central Bank of Jordan Decision Approving Insurance Agent Forms

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In the Name of Allah, the Most Gracious, the Most Merciful

[Logo of the Central Bank of Jordan]

Number: 15866 / 2 / 17
Date: 25 / 2 / 1445 AH
Corresponding to: 10 / 9 / 2023 AD

Dear Respected Insurance Agents,

Subject: Insurance Agent Forms

Based on the provisions of paragraph (b) of Article (109), Articles (19-21), paragraph (c) of Article (82), and paragraph (a) of Article (83) of the Insurance Activities Regulation Law No. (12) of 2021, and based on the provisions of paragraphs (a) and (b) of Article (8), paragraph (17), paragraphs (a) and (b) of Article (18), and paragraph (c) of Article (19) of the Instructions for Licensing, Regulating Activities and Responsibilities No. (10) of 2023, I hereby decide the following:

A) Approval of the following forms:

1. Written declaration form regarding the fulfillment of the conditions stipulated in Articles (19-21) of the Law and the commitment to inform the Central Bank immediately if any of the conditions mentioned therein cease to be met.
   CBJ/ISPs/F1/V1
2. Written declaration form - No conflict of interest. CBJ/ISPs/F2/V1
3. License application form for natural and legal persons to practice insurance agent activities.
   A- Insurance agent (exclusive production/issuance) CBJ/Agent/F1-1/V1 B- Non-exclusive insurance agent CBJ/Agent/F1-2/V1
4. Written declaration form - Accuracy and completeness of data CBJ/Agent/F2/V1

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5. Application form to add an insurance activity branch to the license granted to the agent:
   A- Insurance agent (exclusive production/issuance) CBJ/Agent/F3-1/V1 B- Non-exclusive insurance agent CBJ/Agent/F3-2/V1
6. Application form to open one or more branches for the insurance agent. CBJ/Agent/F4/V1
7. Insurance agent re-registration form.
   A- Insurance agent (exclusive production/issuance) CBJ/Agent/F5-1/V1 B- Non-exclusive insurance agent CBJ/Agent/F5-2/V1
8. Application form for approval at the legal person insurance agent.
   A- Insurance agent (exclusive production/issuance) CBJ/Agent/F6-1/V1 B- Non-exclusive insurance agent CBJ/Agent/F6-2/V1

B) The forms attached to this decision are an integral part of it and shall be read together with it.
C) Decision No. (9) of 2004 and its amendments regarding insurance agent licensing, renewal, and re-registration forms is hereby repealed. D) The provisions of this decision shall take effect as of the date 1/9/2023.

Yours faithfully,

The Governor
Dr. Adel Al-Sharkas

Attached/
Copy to/
Dear Respected Insurance Companies

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[Logo of the Central Bank of Jordan]
Hashemite Kingdom of Jordan
Central Bank of Jordan

Form (1) - Written Declaration - Insurance Service Provider

Based on the provisions of Articles (19-21), paragraph (c) of Article (82), and paragraph (a) of Article (83) of the Insurance Activities Regulation Law No. (12) of 2021:

I, the undersigned: ........................................................
Applicant for license/approval or Licensed/Approved by the Central Bank as:
[ ] Insurance Agent [ ] Insurance Broker [ ] Reinsurance Broker [ ] Actuary [ ] Loss Adjuster [ ] Surveyor [ ] Insurance Consultant

And/or in the capacity of:
[ ] Board Member in a personal capacity [ ] Board Member as a representative of any shareholder [ ] Owner or Partner [ ] Manager of a legal person insurance service provider [ ] Employee of a legal person insurance service provider

At company ........................................................
Hereby declare the following:-

1. Has any final judicial ruling been issued against you for a crime involving moral turpitude or a felony?
   Yes [ ] No [ ]
2. Are you still subject to insolvency procedures or have you been declared bankrupt without your reputation being restored?
   Yes [ ] No [ ]
3. Were you held responsible, in any capacity, as determined by the Central Bank of Jordan Board of Directors, for a serious violation of any provisions of legislation related to financial activities?
   Yes [ ] No [ ]
4. Did you lose your membership in the board of directors of an insurance company by a decision of the Central Bank of Jordan Board of Directors?
   Yes, due to my loss of one of the conditions required for membership in the insurance board of directors.
   Yes, I was removed by a decision of the Central Bank of Jordan Board of Directors.
   No [ ]
5. Was your license to practice any of the insurance service provider activities cancelled or suspended as an administrative penalty, or did you not meet the conditions for re-licensing or registration from the authority that suspended or cancelled the license?
   Yes [ ] No [ ]

I also commit to informing the Central Bank if any of the above matters occur.

Signature: .................... Date: ....................

CBJ/ISPs/F1/V1
1/1

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[Logo of the Central Bank of Jordan]
Hashemite Kingdom of Jordan
Central Bank of Jordan

Form (2)
Written Declaration - No Conflict of Interest - Insurance Service Providers

Based on the provisions of paragraph (a) of Article (83) of the Insurance Activities Regulation Law No. (12) of 2021:

I, the undersigned: ........................................................
Applicant for license/renewal of license/approval or Licensed/Approved by the Central Bank as [ ] Insurance Agent [ ] Insurance Broker [ ] Reinsurance Broker

[ ] Manager of an insurance agent or broker [ ] Employee of an insurance agent or broker

And/or in the capacity of:
[ ] Board Member in a personal capacity [ ] Board Member as a representative of any shareholder [ ] Owner or Partner
At a legal person insurance agent or broker or reinsurance broker ........................................................

Hereby declare the following: -

1. I am not a member of the board of directors of an insurance company in a personal capacity or as a representative of any shareholder, nor am I a senior employee, external auditor, legal advisor, actuarial advisor, or member of its Shariah Supervisory Board at an insurance company.
2. I have no work, marriage, or kinship ties up to the third degree with any of the members of the board of directors of an insurance company, in a personal capacity or as a representative of any shareholder, nor with its senior employee, external auditor, legal advisor, actuarial advisor, or members of its Shariah Supervisory Board.

I also commit to informing the Central Bank if any of the above matters occur.

Signature: ....................
Date: ....................

CBJ/ISPs/F2/V1
1/1

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[Logo of the Central Bank of Jordan]
Hashemite Kingdom of Jordan
Central Bank of Jordan

Form No. (1-1)
Insurance Agent License Application Form

Part One: General Information
1. Name	.
2. License Request	[ ] Natural Person [ ] Legal Person
3. Insurance Agent Classification	[ ] Production Agent [ ] Exclusive Issuance Agent
4. Insurance Company the Agent is contracted with
5. Main Address	P.O. Box:
	Telephone:	Fax:
	Mobile:
6. Electronic Address	Electronic Address (if any)
	Email
7. Date and Place of Birth
8. Nationality
9. Passport Number and Date / or National ID Card
Part Two: Academic Qualifications and Professional Experience
1. Academic Qualifications (mention place and date of obtaining them)

CBJ/Agent/F1-1/V1

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2. Professional Experience (mention place and date of obtaining them)
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Part Three: Other Information
1. Type and branches of insurance for which agency activities are to be practiced

Please specify the type and branches of insurance for which agency activities are to be practiced by placing a check mark (√) in the box corresponding to the branches for which licensing is requested. First: General Insurance Activities Branches

[ ] Accident Insurance
[ ] Motor Vehicle Liability Insurance
[ ] Medical Insurance
[ ] Aircraft Liability Insurance
[ ] Motor Vehicles Insurance
[ ] Ship Liability Insurance
[ ] Railway Locomotives and Coaches Insurance
[ ] General Liability Insurance
[ ] Aircraft Insurance
[ ] Credit Insurance
[ ] Ship Insurance
[ ] Surety Bonds Insurance
[ ] Cargo in Transit Insurance
[ ] Various Financial Loss Insurance
[ ] Fire and Natural Hazards Insurance
[ ] Legal Expenses Insurance
[ ] Other Property Damage Insurance
[ ] Assistance Insurance

CBJ/Agent/F1-1/V1

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Second: Life Insurance Activities Branches
[ ] Life Insurance
[ ] Permanent Health Insurance
[ ] Marriage and Childbirth Insurance
[ ] Management of Collective Pension Funds
[ ] Life Annuities Insurance
[ ] Supplementary Insurance (Personal Accidents) [ ] Investment-Linked Insurance [ ] Medical Insurance

	a) Felony or misdemeanor involving moral turpitude, public morals, or a felony	b) Bankruptcy without reputation restored
2. Has the license applicant previously been convicted of:	Yes [ ] No [ ]	Yes [ ] No [ ]

3. Are you currently subject to insolvency procedures?	Yes [ ] No [ ]
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4. Has your license/registration been suspended by any supervisory and/or regulatory authority for insurance activities? (Specify the licensing authority if any)	Yes [ ] No [ ]

| Part Four: Attachments |

The application is not considered complete unless the Central Bank is provided with all the following data and documentary evidence:-
No.	Attachments	Attached?
1	Two personal photographs.
2	Recent certificate of no criminal record issued by competent authorities in the Hashemite Kingdom of Jordan and its equivalent issued by the country where the license applicant resided during the last three years from the date of application submission.
3	Copy of the National ID Card for Jordanians or Passport.
4	Copy of residence permit and work permit as applicable.
5	Certified copy of academic qualifications and their equivalence from authorized bodies if issued from outside the Hashemite Kingdom of Jordan.
6	Certified copy of professional experience certificates as applicable.
7	Copy of training course certificates as applicable.
8	Proof of enrollment in specialized insurance activities courses during the year preceding the application submission, not less than (15) hours in case of a break from practicing insurance or insurance services activities for more than three years.
9	Written declaration regarding the fulfillment of the conditions stipulated in Articles (19-21) of the Law and the commitment to inform the Central Bank if these conditions are not met, according to the form prepared for this purpose.
10	Written declaration of no conflict of interest regarding the insurance company for which the agent will act, according to the form prepared for this purpose.

CBJ/Agent/F1-1/V1

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No.	Attachments	Attached?
:---	:---
11	Written declaration that his license to practice any of the insurance service provider activities has not previously been cancelled or suspended as an administrative penalty, or that he does not meet the conditions for re-licensing or registration from the authority that suspended or cancelled his license.
12	Certified copy of the agency agreement concluded with the insurance company.
13	Copy of the lease contract or ownership deed for his private office (for both legal person production agents and issuance agents).
14	Declaration of the approved address for service.
15	Written declaration that all data and documents submitted are in accordance with the provisions of the instructions for licensing, regulating activities and responsibilities of insurance agents.
16	Proof of payment of prescribed fees and dues.
17	If the license applicant is a legal person, the above items must be submitted for each of its managers and employees, in addition to the following:-
	a) Manager license application.
	b) Employee approval application to practice agency activities in insurance.
	c) Signed copy of the company contract or establishment deed and articles of association, as applicable.
	d) Names of founders and partners.
	e) Certificate of no criminal record for each owner and partner in the legal person agent issued by competent authorities in the Hashemite Kingdom of Jordan and its equivalent issued by the country where the license applicant resided during the last year from the date of application submission.
	f) Written declaration regarding the fulfillment of the conditions stipulated in Articles (19-21) of the Law, for each owner and partner in the legal person agent.
	g) Written declaration stating no conflict of interest for each owner and partner in the legal person agent with the insurance company for which they will act as agents.
	h) Written declaration from the owners and partners of the legal person stating that none of them have been subject to cancellation or suspension of their license to practice any of the insurance service provider activities as an administrative penalty, or that none of them meet the conditions for re-licensing or registration from the authority that suspended or cancelled the license.
18	If the license applicant is a branch of a foreign legal person, the above items must be submitted in addition to the following:-
	a) Certified certificate of license of the foreign legal person to practice agency activities in insurance issued by the supervisory authority in the country of the headquarters.
	b) Approval of the supervisory authority in the country of the headquarters to open a branch in the Kingdom.

Date of Application Submission
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Name and Signature of Applicant

CBJ/Agent/F1-1/V1

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[Logo of the Central Bank of Jordan]
Hashemite Kingdom of Jordan
Central Bank of Jordan

Form No. (1-2)
Non-Exclusive Insurance Agent License Application Form

Part One: General Information
1. Name
2. Establishment National Number (Applicant for License)
3. Insurance Company the Agent is contracted with
4. Insurance Agent Classification	[ ] Non-Exclusive Production Agent [ ] Non-Exclusive Issuance Agent
5. Main Address	P.O. Box:
	Telephone:	Fax:
	Mobile:
6. Electronic Address	Electronic Address (if any)
	Email

Part Two: Nature of Work, Academic Qualifications and Professional Experience
1. Nature of work of the company applying for the license
2. Goods and/or Services provided by the company for which insurance contracts will be supplemented

CBJ/Agent/F1-2/V1

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3. Academic Qualifications of the Employee Performing Agency Activities (mention place and date of obtaining them)
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4. Professional Experience of the Employee Performing Agency Activities (mention place and date of obtaining them)

Part Three: Other Information
1. Type and branches of insurance for which agency activities are to be practiced

Please specify the type and branches of insurance for which agency activities are to be practiced by placing a check mark (√) in the box corresponding to the branches for which licensing is requested. First: General Insurance Activities Branches [ ] Accident Insurance [ ] General Liability Insurance [ ] Medical Insurance [ ] Credit Insurance [ ] Motor Vehicles Insurance [ ] Surety Bonds Insurance [ ] Fire and Natural Hazards Insurance [ ] Various Financial Loss Insurance [ ] Other Property Damage Insurance [ ] Legal Expenses Insurance [ ] Motor Vehicle Liability Insurance [ ] Assistance Insurance

Second: Life Insurance Activities Branches
[ ] Life Insurance [ ] Supplementary Insurance (Personal Accidents) [ ] Marriage and Childbirth Insurance [ ] Medical Insurance

Third: Life Insurance Activities Branches
(Companies licensed for financial brokerage, investment trusteeship, investment management, issuance management, or financial consulting activities only) [ ] Life Annuities Insurance [ ] Investment-Linked Insurance [ ] Management of Collective Pension Funds

CBJ/Agent/F1-2/V1

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	a) Felony or misdemeanor involving moral turpitude, public morals, or a felony	b) Bankruptcy without reputation restored
2. Has the license applicant previously been convicted of:	Yes [ ] No [ ]	Yes [ ] No [ ]

3. Are you currently subject to insolvency procedures?	Yes [ ] No [ ]
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3. Has your license/registration been suspended by any supervisory and/or regulatory authority for insurance activities? (Specify the licensing authority if any)	Yes [ ] No [ ]

| Part Four: Attachments |

The application is not considered complete unless the Central Bank is provided with all the following data and documentary evidence:-
No.	Attachments	Attached?
	Submit the following items for each of its managers and all employees performing insurance agency activities:-
1	Two personal photographs.
2	Recent certificate of no criminal record issued by competent authorities in the Hashemite Kingdom of Jordan and its equivalent issued by the country where the license applicant resided during the last three years from the date of application submission.
3	Copy of the National ID Card for Jordanians or Passport.
4	Copy of residence permit and work permit as applicable.
5	Certified copy of academic qualifications and their equivalence from authorized bodies if issued from outside the Hashemite Kingdom of Jordan
6	Certified copy of professional experience certificates as applicable.
7	Copy of training course certificates as applicable.
8	Written declaration regarding the fulfillment of the conditions stipulated in Articles (19-21) of the Law and the commitment to inform the Central Bank if these conditions are not met, according to the form prepared for this purpose.
9	Written declaration of no conflict of interest, and the commitment to inform the Central Bank if these conditions are not met during the year, according to the form prepared for this purpose.
10	Written declaration that his license or registration to practice any of the insurance service provider activities has not previously been cancelled or suspended as an administrative penalty, or that he does not meet the conditions for re-licensing or registration from the authority that suspended or cancelled his license.
	In addition to submitting the following:
11	Certified copy of the agency agreement concluded with the insurance company.
12	Updated copy of the company registration certificate from the Companies Control Department.
13	Names of founders and partners of the legal person agent.

CBJ/Agent/F1-2/V1

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No.	Attachments	Attached?
:---	:---
14	Certificate of no criminal record for each owner and partner in the legal person agent from competent authorities in Jordan and its equivalent issued by the country where they resided during the last three years from the date of application submission.
15	Written declaration regarding the fulfillment of the conditions stipulated in Articles (19-21) of the Law, for each owner and partner in the legal person agent.
16	Written declaration stating no conflict of interest for each owner and partner in the legal person agent
17	Written declaration from the owners and partners of the legal person stating that none of them have been subject to cancellation or suspension of their license to practice any of the insurance service provider activities as an administrative penalty, or that none of them meet the conditions for re-licensing or registration from the authority that suspended or cancelled the license.
18	Written declaration that all data and documents submitted are in accordance with the provisions of the instructions for licensing, regulating activities and responsibilities of insurance agents.
19	Declaration of the approved address for service
20	Proof of payment of prescribed fees and dues.

Date of Application Submission
:---
Name and Signature of Applicant

CBJ/Agent/F1-2/V1

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[Logo of the Central Bank of Jordan]
Hashemite Kingdom of Jordan
Central Bank of Jordan

Form No. (2)
Written Declaration - Accuracy and Completeness of Data

I, the undersigned, declare that all data and documentary evidence attached to the insurance agent license application form / application to add an insurance activity branch to the granted license / application to open one or more branches for an insurance agent / insurance agent re-registration form / application form for approval at the legal person insurance agent are correct and in compliance with the provisions of the currently effective instructions for licensing, regulating activities and responsibilities of insurance agents, and therefore I sign.

Name: ....................
Signature: ....................
Date: ....................

CBJ/Agent/F2/V1

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[Logo of the Central Bank of Jordan]
Hashemite Kingdom of Jordan
Central Bank of Jordan

Form No. (3-1)
Application Form to Add an Insurance Branch to an Insurance Agent License (Production / Exclusive Issuance)

Part One: General Information
1. Agent Name
2. Insurance Company the Agent represents
3. Registration Number with the Central Bank
4. Establishment National Number (Legal Person Agent / Exclusive Issuance Natural Person)
5. Insurance Agent Classification	[ ] Production Agent [ ] Natural Person [ ] Exclusive Issuance Agent [ ] Legal Person
6. Request to add branch to license	- Managers of the Legal Person Agent / Name: -
7. Job title and name of the person who will take the exam for the purpose of adding the branch (for Legal Person Agent only)	- Employee(s) performing agency activities at the Legal Person Agent:
8. Date of Application Submission
9. Name and Signature of Applicant:

CBJ/Agent/F3-1/V1

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Part Two: Type and Branches of Insurance to be Added to the License
Please specify the type and branches of insurance to be added to the granted license by placing a check mark (√) in the box corresponding to the branches for which licensing is requested.

First: General Insurance Activities Branches
[ ] Accident Insurance [ ] Motor Vehicle Liability Insurance [ ] Medical Insurance [ ] Aircraft Liability Insurance [ ] Motor Vehicles Insurance [ ] Ship Liability Insurance [ ] Railway Locomotives and Coaches Insurance [ ] General Liability Insurance [ ] Aircraft Insurance [ ] Credit Insurance [ ] Ship Insurance [ ] Surety Bonds Insurance [ ] Cargo in Transit Insurance [ ] Various Financial Loss Insurance [ ] Fire and Natural Hazards Insurance [ ] Legal Expenses Insurance [ ] Other Property Damage Insurance [ ] Assistance Insurance

Second: Life Insurance Activities Branches
[ ] Life Insurance [ ] Permanent Health Insurance [ ] Marriage and Childbirth Insurance [ ] Management of Collective Pension Funds [ ] Life Annuities Insurance [ ] Supplementary Insurance (Personal Accidents) [ ] Investment-Linked Insurance [ ] Medical Insurance

CBJ/Agent/F3-1/V1

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| Part Three: Attachments |

The application is not considered complete unless the Central Bank is provided with all the following data and documentary evidence:-
No.	Attachments	Attached?
1	Proof of fulfillment of the conditions stipulated in Article (6) or Article (7) of the aforementioned Instructions, as applicable.
2	Certified copy of the agency agreement concluded with the insurance company in its amended version including the addition of branch / branches of insurance.
3	Updated copy of the Commercial Register or company registration certificate from the Companies Control Department, as applicable.
4	Recent certificate of no criminal record for the natural person insurance agent issued by competent authorities in the Hashemite Kingdom of Jordan and its equivalent issued by the country where the license applicant resided during the last three years from the date of application submission.
	Recent certificate of no criminal record for each owner, partner, and licensed and/or approved employees performing agency activities at the legal person agent issued by competent authorities in the Hashemite Kingdom of Jordan and its equivalent issued by the country where the license applicant resided during the last year from the date of application submission.
5	Written declaration regarding the fulfillment of the conditions stipulated in Articles (19-21) of the Law and the commitment to inform the Central Bank if these conditions are not met during the year for each natural person insurance agent, owner, partner, and licensed and/or approved employees performing agency activities at the legal person agent, according to the form prepared for this purpose.
6	Written declaration of no conflict of interest, for each natural person insurance agent, owner, partner, and licensed and/or approved employees performing agency activities at the legal person agent, according to the form prepared for this purpose.
7	Proof of participation by the insurance agent and his employees in specialized courses in insurance activities or conferences or seminars in insurance activities during the last two years. (Article 15/f)
8	Written declaration that all data and documents submitted are in accordance with the provisions of the instructions for licensing, regulating activities and responsibilities of insurance agents.
9	Declaration of the approved address for service.
10	Proof of payment of prescribed fees and dues.

Date of Application Submission
:---
Name and Signature of Applicant

CBJ/Agent/F3-1/V1

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[Logo of the Central Bank of Jordan]
Hashemite Kingdom of Jordan
Central Bank of Jordan

Form No. (3-2)
Application Form to Add an Insurance Branch to a Non-Exclusive Insurance Agent License

Part One: General Information
1. Agent Name
2. Insurance Company the Agent represents
3. Registration Number with the Central Bank
4. Insurance Agent Classification	[ ] Non-Exclusive Production Agent [ ] Non-Exclusive Issuance Agent
	- Manager of the Legal Person Agent / Name: -
5. Job title and name of the person who will take the exam for the purpose of adding the branch	- Employee(s) performing agency activities at the Legal Person Agent:

CBJ/Agent/F3-2/V1

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Part Two: Type and Branches of Insurance to be Added to the License
Please specify the type and branches of insurance to be added to the granted license by placing a check mark (√) in the box corresponding to the branches for which licensing is requested.

First: General Insurance Activities Branches
[ ] Accident Insurance [ ] Credit Insurance
[ ] Medical Insurance [ ] Surety Bonds Insurance [ ] Motor Vehicles Insurance [ ] Various Financial Loss Insurance [ ] Fire and Natural Hazards Insurance [ ] Motor Vehicle Liability Insurance [ ] Other Property Damage Insurance [ ] Legal Expenses Insurance [ ] General Liability Insurance [ ] Assistance Insurance

Second: Life Insurance Activities Branches
[ ] Life Insurance [ ] Supplementary Insurance (Personal Accidents) [ ] Marriage and Childbirth Insurance [ ] Medical Insurance

Third: Life Insurance Activities Branches
(Companies licensed for financial brokerage, investment trusteeship, investment management, issuance management, or financial consulting activities only) [ ] Life Annuities Insurance [ ] Investment-Linked Insurance [ ] Management of Collective Pension Funds

| Part Three: Attachments |

The application is not considered complete unless the Central Bank is provided with all the following data and documentary evidence:-
No.	Attachments	Attached?
1	Proof of fulfillment of the conditions stipulated in Article (6) of the aforementioned Instructions.
2	Certified copy of the agency agreement concluded with the insurance company in its amended version including the addition of branch / branches of insurance.
3	Updated copy of the company registration certificate from the Companies Control Department.

CBJ/Agent/F3-2/V1

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No.	Attachments	Attached?
:---	:---
4	Recent certificate of no criminal record for each owner, partner, and licensed and/or approved employees performing agency activities at the legal person agent issued by competent authorities in the Hashemite Kingdom of Jordan and its equivalent issued by the country where they resided during the last three years from the date of application submission.
5	Written declaration regarding the fulfillment of the conditions stipulated in Articles (19-21) of the Law and the commitment to inform the Central Bank if these conditions are not met for each owner, partner, and employees at the legal person agent, according to the form prepared for this purpose.
6	Written declaration of no conflict of interest for each owner, partner, and employees at the legal person agent, according to the form prepared for this purpose.
7	Proof of participation by the manager and his employees in specialized courses in insurance activities as applicable (Article 15 f).
8	Written declaration that all data and documents submitted are in accordance with the provisions of the instructions for licensing, regulating activities and responsibilities of insurance agents.
9	Declaration of the approved address for service.
10	Proof of payment of prescribed fees and dues.

Date of Application Submission
:---
Name and Signature of Applicant

CBJ/Agent/F3-2/V1

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[Logo of the Central Bank of Jordan]
Hashemite Kingdom of Jordan
Central Bank of Jordan

Form No. (4)
Application Form to Open One or More Branches for a Legal Person Insurance Agent

Part One: General Information
1. Agent Name
2. Registration Number with the Central Bank
3. Establishment National Number
4. Insurance Company the Agent represents
5. Insurance Agent Classification	[ ] Production Agent [ ] Issuance Agent
6. Number and location of currently operating branches
7. Number and location of branches intended to be added
8. Main Address of the Insurance Agent	P.O. Box:
	Landline Telephone:	Fax:
	Mobile Telephone:
9. Email Address (if any)

CBJ/Agent/F4/V1

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| Part Five: Attachments |

The application is not considered complete unless the Central Bank is provided with all the following data and documentary evidence:-
No.
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