FORM 1 Regulation 10(1) INSURANCE ACT 1966 INSURANCE (APPEALS) REGULATIONS 2025 NOTICE OF APPEAL Date of Service of Notice on Appeals Secretary: Name of Appellant: NRIC No. / Passport No. / FIN No. / Company Registration No.* of the Appellant: Address(es) of the Appellant: Email address of the Appellant*: Telephone Number(s) of the Appellant: Name of each of the Appellant’s authorised representative or legal representative*: Address of each of the Appellant’s authorised representative or legal representative*: Address for service of documents: Email address for service of documents (if applicable# ): This appeal is made under section ___ of the Insurance Act 1966. The appeal is against the decision of the Authority of: (state the date of the decision of the Authority and provide a brief description of decision of the Authority appealed against, a brief description of the grounds for appealing

against the decision of the Authority, and identify whether the appeal is against the whole, or only part, of the decision of the Authority)

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Signature of Appellant/ authorised representative or legal representative acting for the Appellant*

• Delete if inapplicable

By providing an email address for service of documents, the Appellant consents to service of

documents by email