Form LIB - FINAL

APPLICATION FOR LICENCE TO CARRY ON
LABUAN INSURANCE AND INSURANCE RELATED BUSINESS
IMPORTANT NOTES
1. The completed application form and supporting documents should be submitted to:
Head of Business Operations Unit
Labuan Financial Services Authority
Level 17, Main Office Tower
Financial Park Complex
Jalan Merdeka
87000 Labuan F.T.
Malaysia
2. Applicant may also submit a soft copy of the completed application form and supporting
documents via email to [email protected] for preliminary review by the officer.
3. Submission of application which does not comply with Labuan FSA’s requirement or which
are unsatisfactory may be returned.
4. The form and supporting documents serves as general requirement of the application,
Labuan FSA reserves the right to request for additional information and/or documents to
support the application.
5. Any information supplied pursuant to this form will be dealt with in confidence in
accordance with Section 178 of the Labuan Financial Services and Securities Act
2010/Section 139 of the Labuan Islamic Financial Services and Securities Act 2010.
6. Documents may be certified by any authorised person including, but not limited to,
commissioner for oaths, notary public, certified public accountants, advocates or solicitors,
company secretaries and Malaysian/foreign embassies. Copy of bank statements must be
certified by the bank. Where documents are not in the national language of Malaysia or in
English, please provide English-translated version of the documents, duly
certified/notarized.
7. This document belongs to Labuan FSA, no modification or tampering with the format or its
contents is permitted.
8. Labuan FSA has a whistle blowing policy in place where suppliers, consultants or even
members of the public can report to the Designated Officers in writing as per the Whistle
Blowing Disclosure Form if there is any element of wrongdoings by any staff of Labuan
FSA or its subsidiaries in relation to the application or licence being awarded.
9. For details of applicable legislations and guidelines pertaining to insurance and insurance
related business, please visit our website at www.labuanibfc.com.my.
10. Processing fee and client charter:

Type of Processing fee
Client Charter*
Processing RM USD
Normal 1,000.00 350.00 30 working days
Fast Track 4,500.00 1,550.00 15 working days
*Client Charter will be calculated upon complete submission of documentation and information to Labuan FSA.
GENERAL INFORMATION
Important: All fields are mandatory and should not be left blank
1. Party responsible for submission of application 1
Applicant’s Shareholder/Head Office Labuan Trust Company
Others: _______________________ Labuan Insurance/Underwriting

(please specify) Manager
2. Officer responsible for submission of application
Name :________________________ Company :___________________________
Designation :_________________________ Contact No. :___________________________
Email :_________________________ Signature :___________________________
3. How do you know about Labuan IBFC
Website Newspaper/Media
Previous Experience Business Referral
Labuan Trust Company Labuan IBFC Inc. Sdn. Bhd.2
Others: _______________________
(please specify)
4. Consent for disclosure of information to be used for marketing/promotional purposes by Labuan

FSA and Labuan IBFC Inc. Sdn. Bhd.
Yes No
1 With the exception of the applicant’s shareholder/head office, party responsible for submission of application is
required to submit the duly completed Statutory Declaration as attached in Appendix I.
2 Labuan IBFC Inc. Sdn. Bhd. was incorporated in July 2008 as the sole official Malaysian agency authorised to
promote, market and develop the benefits of Labuan IBFC as the premier international business and financial centre
in Asia Pacific.
Application for Licence to Carry on Labuan Insurance and Insurance-Related Business 2

FORM LIB
APPLICATION FOR LICENCE TO CARRY ON LABUAN INSURANCE AND

INSURANCE RELATED BUSINESS
Sections 103 and 104, Labuan Financial Services and Securities Act 2010
Sections 78 and 79, Labuan Islamic Financial Services and Securities Act 2010
PART I : PROFILE OF APPLICANT
Name of Applicant
a. (Refers to the proposed Labuan
company)
Conventional Takaful
Conventional with Takaful Window
Please tick (√) the regulated activities to be undertaken:

Insurance / Takaful:_________________
(please specify Life or General)
Reinsurance / Retakaful:_______________
(please specify Life or General)
Type of Licence Applied Captive:___________________
b.
(Please tick (√) the appropriate box) (please specify type of captive and structure e.g. Protected Cell
Company structure )
Broker:____________________
(please specify Life, General or Composite)
Insurance Manager
Underwriting Manager – Lloyds’ Syndicate
Managed Underwriting Manager
Full-Fledged Underwriting Manager

Labuan Company - Subsidiary
Nature of Legal Entity Foreign Labuan Company - Branch

c.
(Please tick (√) the appropriate box)
Branch of Malaysian Insurer
Own Management Office in Labuan OR

Appoint an Underwriting Manager (please specify the proposed
Type of management to be Underwriting Manager):
d. established ______________________________ ) OR
(Please tick (√) the appropriate box) Appoint an Insurance Manager (please specify the proposed
Insurance Manager):
______________________________ )
Please indicate if applicant intend to establish:-
Marketing office (except for captive and insurance broker,
applicant is required to have management office in Labuan)
Co-located office (not applicable to application for licence as an

insurance/underwriting manager)

FORM LIB
Sections 78 and 79, Labuan Islamic Financial Services and Securities Act 2010
PART I : PROFILE OF APPLICANT
Proposed Paid-up
e. Capital/Working Fund
(Please specify currency used)
Proposed Seed Capital for

f. Takaful Window
(Please specify currency used)
Country of Percentage of
Name of Shareholder(s)
Origin Shareholding(s)
Proposed Shareholder(s)
g. (Each of shareholder is required to
complete Part II and/or Part III)
Name of Directors/
Nationality Position to be Held
Principal Officer
Proposed Directors3/ Principal

Officer
h. (Each of Director/ Principal Officer
is required to complete Part IV)
Years of Experience In
Name of Advisor(s) Nationality
Islamic Financial Business
Proposed Shariah Advisor(s)

i. (Each of Shariah Advisor is required
to complete Part IV) – If applicable
3The number of proposed directors must be in accordance to the Prudential Framework of Corporate Governance for
Labuan Insurance and Insurance-Related Companies.

FORM LIB
PART II : PROFILE OF CORPORATE SHAREHOLDER(S)

a. Name of Company/ Head Office
b. Company Address
c. Nature and Type of Business

Incorporation / Registration
d.
Number
Date and Place of Incorporation /
e.
Registration
Date, Type of Licence and
f.
Licence Number
(if applicable)
g. Home Supervisory Authority (if

applicable)
Retained
Profits /
Year Paid-Up Capital Other Reserves
Accumulated
Shareholders’ Fund Losses
(Please specify currency and amount
h.
for the latest three (3) years Audited
Financial Statements)
Total Profit/(Loss)
Year Total Assets
Liabilities Before Tax
Financial Performance
(Please specify currency and amount
i.
for the latest (3) three years Audited
Financial Statements)
Country of Percentage of
Name of Shareholder(s)
Origin Shareholding(s)
j. Shareholder(s)
Nature of
Name of Director(s) Nationality Appointment
(executive or non-
executive)
k. Board of Director(s)
Agency Rating Date

l. Credit Rating, if applicable
Any Other Information Relevant

m. For Consideration of the
Application

FORM LIB
PART III : PROFILE OF INDIVIDUAL SHAREHOLDER(S)

a. Salutation
Name
b. (as per NRIC/passport)
Please tick (√) if the individual is a PEP
Date and Place of
c.
Birth
d. Gender Male Female
e. Nationality
Old IC No.:
NRIC Details
f.
(for Malaysian) NRIC No.:
Passport No.:
Expiry Date:
Country of Issue:
Passport Details Issuing Authority:

g. Length of residence in Malaysia:
(for Non-Malaysian)
Any work permit applied prior to this application:
No Yes
(please provide certified true
copy of the work permit)
a) Net Worth Statement Certified by Qualified Accountant; or

Currency and Amount
Financial Net Worth Total Assets
(latest three months
bank statement duly Total Liabilities
certified by the Bank or
h. net worth statement b) Bank Statement / Online Bank Statement Certified by the Bank
prepared and certified
by Qualified Statement Currency
Name of Bank Type of Account
Accountant) Date and Amount
i. Curriculum Vitae of Individual Shareholder
Section A: Education(s)
Name of School/College/
Type of Qualification/ Certification Year Qualification Obtained
University/Others

FORM LIB
PART III : PROFILE OF INDIVIDUAL SHAREHOLDER(S)

Section B: Professional Qualification(s)
Type of Qualification/ Certification Name of Institution Year Qualification Obtained
Section C: Membership of Professional Body(s)
Type and Details of Membership Name of Institution Year Membership Obtained
Section D: Past and Current Work Experience(s)
Date
(dd/mm/yy)
Name of Employer Designation Key Areas of Responsibilities
From To
Section E: Directorship Held in Other Company(s)

Date of
Name of Corporation Place of Incorporation Nature of Appointment
Appointment (executive or non-executive)
(dd/mm/yy)

FORM LIB
PART IV : PROFILE OF PROPOSED DIRECTOR(S)/PRINCIPAL OFFICER/SHARIAH ADVISOR/ACTUARY(S)

a. Position to be held
b. Salutation
Name
c. (as per NRIC/
passport) Please tick (√) if the individual is a PEP
Date and Place of

d.
Birth
e. Gender Male Female
f. Nationality
Old IC No.:
NRIC Details
g.
(for Malaysian) NRIC No.:
Passport No.:
Expiry Date:
Country of Issue:
Issuing Authority:
Passport Details
h.
(for Non-Malaysian) Length of residence in Malaysia:
Any work permit applied prior to this application:
No Yes
(please provide certified true
copy of the work permit)
i. Curriculum Vitae of Director/Principal Officer/Shariah Advisor
Section A: Tertiary / Highest Education(s)
Type of Qualification/ Certification Name of School/College/ University/Others Year Qualification Obtained
Section B : Professional Qualification(s)
Type of Qualification/ Certification Name of Institution Year Qualification Obtained

FORM LIB
PART IV : PROFILE OF PROPOSED DIRECTOR(S)/PRINCIPAL OFFICER/SHARIAH ADVISOR/ACTUARY(S)

Section C: Membership of Professional Body(s)
Type and Details of Membership Name of Institution Year Membership Obtained
Section D: Past and Current Work Experience(s)
Date
(dd/mm/yy)
Name of Employer4 Designation Key Areas of Responsibilities
From To
Section E: Directorship Held in Other Company(s)
Place of Date of
Name of Corporation Nature of Appointment
Incorporation Appointment (executive or non-executive)
(dd/mm/yy)
RSON
4 If the position applied for requires approval from relevant authority, please give detail of the approving authority
(applicable to current employment only).

FORM LIB
PART V : PARTICULARS OF THE APPLICATION

Section A: Business Plan (Please fill in the details, where applicable)
i) General Business Plan
a. Objective of Establishment
Type of Insurance Life Insurance

b. (Please tick (√) the appropriate box) General Insurance
Target Market %
Target Market
c. (to specify whether it is individual and/or Individual
corporate client and the percentage) Corporate Client
Territorial Scope %
Territorial Scope
d.
(to specify the country and percentage)
e. Marketing Strategy
Non- Expected
Category Malaysian Total
Malaysian Remuneration
(a) Managerial &
Professional
(b) Technical &
Supervisory
(c) Production /
Operation
f. Proposed Manpower Planning Workers
- Skilled
- Unskilled
(d) Clerical &
General
Workers
Total
(a)+(b)+(c)+(d)
Functional Structure of Management

g. Office in Labuan
Functional Structure of Co-Located Office/

h. Marketing Office
(if any)

FORM LIB

ii) Additional Information for Applicant Undertaking Life Insurance Business
Ordinary Life
The Composition of Life Insurance Ordinary Life and Investment-
a. Linked
Others
b. Retention level
c. Reinsurance arrangement
 The structure of reinsurance

arrangement
 Proposed reinsurers and shares of

participation
Choice of Distribution Channels

d. (e.g. life brokers and/or other financial
institutions)
iii) Additional Information for Applicant Undertaking General Insurance Business (include captive insurance
business)
Fire
Marine
Engineering
Class of insurance Motor
a.
Accident
Miscellaneous
Others
b. Retention level (percentages)
c. Reinsurance arrangement
 The structure of reinsurance

arrangement
 Proposed reinsurers and shares of

participation

FORM LIB

Fronting arrangement
d. (e.g: name of fronting insurer and percentage
retain by fronting insurer, applicable for
captive insurance business only, if applicable)
e. Loss history for the past three years

(for captive insurance business only)
Type of Risk/Year Year 1 Year 2 Year 3
iv) Additional Information for Applicant Undertaking Insurance Broking Business
Insurance
Type of broking business
a. (Please tick (√) the appropriate box) Reinsurance
Financial Advisory
Sources of insurance/insurance providers

c. (for life broker only which has been identified
earlier)
v) Additional Information for Applicant Providing Underwriting Management Services
Pure Underwriting
Type of services
a. (Please tick (√) the appropriate box) Administration Services
Both Underwriting and Administration Services
Name of syndicate
b.
(for Lloyds’ Syndicate only)
Underwriting capacity
c. (e.g. the authorized amount that given to the
underwriter to underwrite)
Fire
Marine
Engineering
Class of insurance
e. (applicable to underwriting manager providing Motor
pure underwriting services)
Accident
Miscellaneous
Others

FORM LIB

Section B: Three Years Financial Projection (*fill in where applicable)
Currency:
Statement of Comprehensive Income Year 1 Year 2 Year 3
INCOME
Gross earned premiums on insurance
contracts
Less: Reinsurers’ share of gross premiums
on insurance
Net Earned Insurance Premiums
Commission income / brokerage income*
Investment income
Other operating income
Total Income
CLAIMS AND EXPENSES
Gross claims paid
Claims ceded to reinsurers

Gross change in provision for outstanding
claims
Net Claims Incurred
Commission expenses
General and administrative expenses
Other operating expenses
Total Claims and Expenses
Income / (Loss) Before Tax
Tax
Income / (Loss) After Tax
Statement of Financial Position Year 1 Year 2 Year 3
ASSETS
Non-current assets
Current assets

FORM LIB

Total Assets
LIABILITIES
Long term liabilities
Short term liabilities
Total Liabilities
SHAREHOLDERS’ FUNDS / HEAD
OFFICE ACCOUNT
Head office account / paid up capital
Retained profits / accumulated losses
Other reserves
Total Shareholders’ Funds / Head Office
Account
Note:
1. Please ensure the three years projection is realistic and reasonable.
2. Please provide basis of assumption in deriving to the projected figure.
3. The above information is a guidance for the applicant to complete the financial projection.

FORM LIB
PART VI : SUPPORTING DOCUMENTS

(Please √ at the appropriate box and provide reason(s)/justification(s) for any non-submission)
For
For
No Documents Labuan
Applicant
FSA
Part II: Corporate Shareholder(s)
1. Detailed information of applicant’s shareholder(s) or head office:
a) Group corporate shareholding structure including the applicant
b) Certified true copy of certificate of incorporation
c) Certified true copy of certificate of licence granted by relevant authority(s) in its
home country – (if applicable)
d) Letter of awareness or approvals of authorities from the home country, which
includes5:
(i) Statement of no objection towards the establishment of a subsidiary or branch in
Labuan.
(ii) Confirmation that the applicant’s shareholder or head office is of good financial
standing.
(iii) Agreement to co-operate in the supervision of the proposed subsidiary or branch
in Labuan in terms of Insurance Core Principles issued by International
Association of Insurance Supervisors or other applicable regulatory standards.
e) Certified true copy of board resolution or minutes of general meeting which approved
the setting up of the applicant
f) Certified true copy of memorandum & articles of association
g) Copy of two (2) years audited financial statements/annual reports
2. Letter of guarantee or undertaking by:
a) applicant’s shareholder, if applicant is a subsidiary (format as per Appendix I)
b) applicant’s head office, if applicant is a branch (format as per Appendix II)
(for applications from Lloyd’s Syndicates please provide the chain of security letter from Lloyd’s of
London)
Part III: Individual Shareholder(s)
1. Certified true copy of NRIC (Malaysian) or passport (non-Malaysian)
2. Certified true copy of relevant academic and professional certificates
3. Two (2) referral letters from institutions and/or professional bodies
Net worth statement by qualified accountant or certified true copy of the latest three
4.
months of bank statements indicating the amount of funds available
5. Letter of Guarantee by Individual Shareholder as per Appendix III
Statutory Declaration by Individual Shareholder/Director/Principal Officer on Fit and
6.
Proper Person as per Appendix IV.
7. Enhance Due Diligence report from the trust company / service provider, if applicable.
Part IV: Director(s) / Principal Officer / Shariah Advisor / Actuary(s)
1. Certified true copy of NRIC (Malaysian) or passport (non-Malaysian)
2. Certified true copy of relevant academic and professional certificates
Two (2) referral letters from institutions and/or professional bodies (not applicable for
3.
appointment within the group of companies)
Statutory Declaration by Individual Shareholder/Director/Principal Officer on Fit and
4.
Proper Person as per Appendix IV.
5. Enhance Due Diligence report from the trust company / service provider, if applicable.
Other Supporting Documents
5
This is applicable for applicant who are regulated by its home supervisory authority

FORM LIB
PART VI : SUPPORTING DOCUMENTS

(Please √ at the appropriate box and provide reason(s)/justification(s) for any non-submission)
For
For
No Documents Labuan
Applicant
FSA
1. Proposed organisation chart of the applicant
Framework on Know-Your-Customers’ policy and compliance to the Anti-Money
2.
Laundering, Anti-Terrorism Financing and Proceeds of Unlawful Activities Act 2001
Risk Management and Internal Control Policy, if any. The policy must be available for
3.
inspection once the licence is granted.
Investment Management Policy, if any. The policy must be available for inspection once
4.
the licence is granted.
4. Declaration of True and Correct Information Submitted as per Appendix V.
Statutory Declaration by Services Provider Responsible for Submission of Application as
5.
per Appendix VI.

FORM LIB
Appendix I
Letterhead of Applicant’s Corporate Shareholder
[Date]
The Director General
Financial Park Labuan, Jalan Merdeka
87000 Federal Territory of Labuan
Malaysia
Dear Sir,
LETTER OF GUARANTEE
The application by [name of applicant], a subsidiary of [name of shareholder] to Labuan FSA
dated [date] for a licence to carry on Labuan [type of licence] business under the provisions of the
Labuan Financial Services and Securities Act 2010/Labuan Islamic Financial Services and
Securities Act 2010 [delete whichever not applicable] (hereinafter referred to as “the Act”) refers.
We, being the shareholder, do hereby irrevocably and unconditionally guarantee and undertake
in respect of [name of applicant]’s Labuan [type of licence] business, that during validity of [name
of applicant]’s licence and its operation in Labuan IBFC, it shall comply with the following:
a. The financial obligations and requirements imposed under the Act on it and shall meet
it’s liabilities in respect of its Labuan [type of licence] business.
b. The requirement to obtain a prior written approval from Labuan FSA for:
i. any change of [name of applicant]’s shareholder who holds ten percent centum
or more of its paid up capital.
ii. any appointment of [name of applicant]’s director and principal officer, whom
shall be of a fit and proper person.
iii. any amendment or alteration to any of [name of applicant]’s constituent
documents.
c. The requirement to immediately notify Labuan FSA of any amendment or alteration

to any information which had been furnished to Labuan FSA in connection with the
application for the Labuan [type of licence] licence.
We shall when so demanded in writing by Labuan FSA, on first demand, make good, meet and
honour the above requirements including, but not limited to, paying such sum of money in
satisfaction of such financial obligations, requirements and liabilities to the extent they are
properly due in such currency as may be specified by Labuan FSA, and on the basis such
payments extinguish such financial obligations, requirements and liabilities of [name of applicant].
Yours faithfully,
For and on behalf of
[Name of shareholder]
___________________
[Name]

FORM LIB
Director
Appendix II
Letterhead of Head Office
[Date]
Malaysia
Dear Sir,
LETTER OF UNDERTAKING
The application by [name of applicant], a branch of [name of head office], to Labuan FSA dated
[date] for a licence to carry on Labuan [type of licence] business under the provisions of the
Labuan Financial Services and Securities Act 2010/Labuan Islamic Financial Services and
Securities Act 2010 [delete whichever not applicable] (hereinafter referred to as “the Act”) refers.
We, being the head office, do hereby irrevocably and unconditionally undertake in respect of the
[name of applicant]’s Labuan [type of licence] business, that during validity of [name of applicant]’s
licence and its operation in Labuan IBFC, it shall comply with the following:
a. The financial obligations and requirements imposed under the Act on it and shall meet it’s
liabilities in respect of its Labuan [type of licence] business.
b. The requirement to obtain a prior written approval from Labuan FSA for any appointment
of [name of applicant]’s principal officer whom shall be of a fit and proper person.
c. The requirement to notify Labuan FSA in writing within three months after the date of:
i. any change of [name of applicant]’s shareholder who holds ten per centum or more
of its paid up capital.
ii. any appointment of [name of applicant]’s director, whom shall be of a fit and proper
person.
iii. any amendment or alteration to any of [name of applicant]’s constituent documents.
d. The requirement to immediately notify Labuan FSA of any amendment or alteration to any
information which had been furnished to Labuan FSA in connection with the application
for the Labuan [type of licence] licence.
We shall when so demanded in writing by Labuan FSA, on first demand, make good, meet and
payments extinguish such financial obligations, requirements and liabilities of [name of applicant]
and the head office.
Yours faithfully,
For and on behalf of
[Name of head office]
___________________
[Name]
Director

FORM LIB
Appendix III
Name and Address of Individual Shareholder
[Date]

Malaysia
Dear Sir,
LETTER OF GUARANTEE
The application by [name of applicant], to Labuan FSA dated [date] for a licence to carry on
Labuan [type of licence] business under the provisions of the Labuan Financial Services and
Securities Act 2010/Labuan Islamic Financial Services and Securities Act 2010 [delete whichever
not applicable] (hereinafter referred to as “the Act”) refers.
I, being the [percentage of shareholding] shareholder of [name of applicant], do hereby irrevocably

and unconditionally guarantee and undertake in respect of [name of applicant]’s Labuan [type of
licence] business that during validity of [name of applicant]’s licence and its operation in Labuan
IBFC, it shall comply with the following:
a. The financial obligations and requirements imposed under the Act on it and shall meet it’s
liabilities in respect of its Labuan [type of licence] business.
b. The requirement to obtain a prior written approval from Labuan FSA for:
i. any change of the [name of applicant]’s shareholder who holds ten per centum or
more of its paid-up capital.
ii. any appointment of [name of applicant]’s director and principal officer, whom shall
be of a fit and proper person.
iii. any amendment or alteration to any of [name of applicant]’s constituent documents.
c. The requirement to immediately notify Labuan FSA of any amendment or alteration to any
information which had been furnished to Labuan FSA in connection with the application
for the Labuan [type of licence] licence.
I shall when so demanded in writing by Labuan FSA, on first demand, make good, meet and
payments extinguish such financial obligations, requirements and liabilities of [name of applicant].
Yours faithfully,
___________________
[Name of shareholder]
[NRIC or Passport No.]
Appendix IV

FORM LIB
STATUTORY DECLARATION BY INDIVIDUAL SHAREHOLDER/DIRECTOR/PRINCIPAL OFFICER

ON FIT AND PROPER PERSON
I, ……………………………………………..NRIC/Passport No:……………………………….., a
proposed director/principal officer of…………………………………………………..(name of the Labuan
company), do hereby solemnly and sincerely declare that:
1. I have read Section 4 of the Labuan Financial Services and Securities Act 2010
(LFSSA)/Section 4 of the Labuan Islamic Financial Services and Securities Act 2010
(LIFSSA) and the Guidelines on Fit and Proper Person Requirements issued on 11
February 2014 (the Guidelines).
2. to the best of my knowledge and belief in making this declaration and/or submitting the
attached documents in relation to this declaration, that I am a fit and proper person
based on the criteria stated under the said Section 4 of LFSSA/Section 4 of LIFSSA and
the Guidelines.
3. the information given in this declaration and in the attached documents (if any) are
accurate, true and complete.
4. I understand that if it is found that I have made false declaration herein and/or in the
attached document (if any), Labuan FSA is entitled to take any legal action including
disqualifying myself from acting in the capacity expressly mentioned herein.
And I make this solemn declaration conscientiously believing the same to be true and by virtue of the
provisions of the Statutory Declaration Act 1960 / ……………………………………………...(please
state any other relevant provisions).
Subscribed and solemnly declared by the above

named …………………….
At ………………………………. ……………………………….
In the State of …………………….. Signature
This …day of …. 20..
Before me,
…………………………..
(Commissioner for Oaths/Notary Public)

FORM LIB
Appendix V
DECLARATION OF TRUE AND CORRECT INFORMATION SUBMITTED

I……………………………………………………..NRIC/Passport No:…………….......................................
the …………..…………………….………(position in the applicant’s shareholder/head office)
of……………………….......................................................................................(name of the applicant’s
shareholder/head office), do hereby solemnly and sincerely declare that:
1. all information submitted in this application including all attachments, forms, documents and
forwarding letters are:
a. submitted pursuant to the provisions of Sections 103 and 104 of the Labuan Financial Services
and Securities Act 2010 (LFSSA)/Sections 78 and 79 of the Labuan Islamic Financial Services
and Securities Act 2010 (LIFSSA).
b. accurate, true and correct and that all estimations provided are fair and reasonable.
2. I am aware that if I make any misrepresentation herein this application, it is an offence punishable
pursuant to Section 192 of the LFSSA/ Section 152 of the LIFSSA.
3. a printed signed copy of this application which reflects the same information provided in this
application is being kept at the office of my principal or our appointed Labuan trust
company/Labuan insurance manager/Labuan underwriting manager being the agent approved
by Labuan FSA.
And I make this solemn declaration conscientiously believing the same to be true and by virtue of the
provisions of the Statutory Declaration Act 1960 / ……………………………………………...(please state
any other relevant provisions).
Subscribed and solemnly declared by the above

named ……………………..................
At ………………………………........... ……………………………….
In the State of ……………………....... Signature
This …....day of …................... 20......
Before me,
…………………………..

FORM LIB
Appendix VI
STATUTORY DECLARATION BY SERVICE PROVIDER RESPONSIBLE FOR

SUBMISSION OF APPLICATION
I, ……………………..(name) of …………………………….(address) NRIC/Passport No:…………… the

authorized officer of ………………………………………..(name of trust company/insurance
manager/underwriting manager/other service providers) being the party responsible for the submission
of application for ……………………………………..(name of applicant) do solemnly and sincerely
declare that in relation to the above application:
1. I have conducted due diligence process on…………………………. (name of applicant) and on its
director(s) and shareholder(s) and other persons or companies that involved and related to the
application and satisfied with the result thereof.
2. I am satisfied that the requirements of all legislations and applicable guidelines including but not
limited to Guidelines on Fit and Proper Person Requirements and Anti-Terrorism Financing and
Proceeds of Unlawful Activities Act 2001in respect of the above application have been complied
with.
And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the
provisions of the Statutory Declaration Act 1960 / ……………………………………………...(please state
any other relevant provisions).
Subscribed and solemnly declared by

the above named …………………….
At ………………………………. ……………………………….
In the State of …………………….. Signature
This …day of …. 20..
Before me,
…………………………..

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APPLICATION FOR LICENCE TO CARRY ON

LABUAN INSURANCE AND INSURANCE RELATED BUSINESS

10. Processing fee and client charter:

1. Party responsible for submission of application 1

Applicant’s Shareholder/Head Office Labuan Trust Company

Others: _______________________ Labuan Insurance/Underwriting

2. Officer responsible for submission of application

Name :________________________ Company :___________________________

Designation :_________________________ Contact No. :___________________________

Email :_________________________ Signature :___________________________

3. How do you know about Labuan IBFC

Previous Experience Business Referral

Labuan Trust Company Labuan IBFC Inc. Sdn. Bhd.2

4. Consent for disclosure of information to be used for marketing/promotional purposes by Labuan

Application for Licence to Carry on Labuan Insurance and Insurance-Related Business 2

APPLICATION FOR LICENCE TO CARRY ON LABUAN INSURANCE AND

Conventional with Takaful Window

Please tick (√) the regulated activities to be undertaken:

Managed Underwriting Manager

Full-Fledged Underwriting Manager

Nature of Legal Entity Foreign Labuan Company - Branch

Own Management Office in Labuan OR

Co-located office (not applicable to application for licence as an

Application for Licence to Carry on Labuan Insurance and Insurance-Related Business 3

Proposed Seed Capital for

Proposed Directors3/ Principal

Proposed Shariah Advisor(s)

Application for Licence to Carry on Labuan Insurance and Insurance-Related Business 4

PART II : PROFILE OF CORPORATE SHAREHOLDER(S)

a. Name of Company/ Head Office

c. Nature and Type of Business

g. Home Supervisory Authority (if

Agency Rating Date

Any Other Information Relevant

Application for Licence to Carry on Labuan Insurance and Insurance-Related Business 5

PART III : PROFILE OF INDIVIDUAL SHAREHOLDER(S)

d. Gender Male Female

Passport Details Issuing Authority:

a) Net Worth Statement Certified by Qualified Accountant; or

i. Curriculum Vitae of Individual Shareholder

Application for Licence to Carry on Labuan Insurance and Insurance-Related Business 6

PART III : PROFILE OF INDIVIDUAL SHAREHOLDER(S)

Section B: Professional Qualification(s)

Type of Qualification/ Certification Name of Institution Year Qualification Obtained

Section C: Membership of Professional Body(s)

Type and Details of Membership Name of Institution Year Membership Obtained

Section D: Past and Current Work Experience(s)

Section E: Directorship Held in Other Company(s)

Application for Licence to Carry on Labuan Insurance and Insurance-Related Business 7

PART IV : PROFILE OF PROPOSED DIRECTOR(S)/PRINCIPAL OFFICER/SHARIAH ADVISOR/ACTUARY(S)

Date and Place of

e. Gender Male Female

Any work permit applied prior to this application:

Section A: Tertiary / Highest Education(s)

Type of Qualification/ Certification Name of School/College/ University/Others Year Qualification Obtained

Section B : Professional Qualification(s)

Type of Qualification/ Certification Name of Institution Year Qualification Obtained

Application for Licence to Carry on Labuan Insurance and Insurance-Related Business 8

PART IV : PROFILE OF PROPOSED DIRECTOR(S)/PRINCIPAL OFFICER/SHARIAH ADVISOR/ACTUARY(S)

Name : Company :___

Designation :_ Contact No. :___

Email :_ Signature :___