FORM 13

THE INSURANCE ACT, 2018

PART IV- INTERMEDIARIES

APPLICATION FOR RENEWAL OF CERTIFICATE OF REGISTRATION AS

AN ADJUSTER (INDIVIDUAL) / ADJUSTER (COMPANY)
(Sections 110 to 124)
The Insurance (Intermediaries) Registration Regulations, 2020 (“Regulations”)

TO: THE CENTRAL BANK OF TRINIDAD AND TOBAGO (“the Central Bank”)

I, (BLOCK LETTERS), hereby apply for the renewal of the Certificate of Registration described
herein :

as an individual Insurance Adjuster (Block Letter)

OR
as Insurance Adjuster Company registered as (Block Letters)
(Please Check the Applicable Box).

Current Certificate Number: Length of Current Certificate (yrs.) :

1 2 3

Effective Period Issued (mm/dd/yyyy):

to Date:
Signature of Applicant (individual)
I enclose the official original receipt CB 16 dated OR

(mm/dd/yyyy Date:
(mm/dd/yyyy
in the amount of $ as evidence
of payment of the prescribed fee. Signature of Applicant for Adjuster (Company)
Position in Adjuster Company MD/CEO/Secretary
MD CEO Secretary

DIRECTIONS
ANSWER ALL QUESTIONS

1. Renewal applications must be submitted to the Central Bank not later than twenty (20) business days before the
expiration of the Certificate of Registration, in the year of expiration. The Application/ Annual Fee is $3,500.00 for Adjuster
(Individual) and $6,500.00 for Adjuster (Company). If you do not submit your application within that time frame, you must
submit a new application for registration.

2. The Central Bank must be notified of all changes in the following: home/registered address, directors and secretary
(in the case of an Adjuster Company) and in any other material changes in the adjuster’s status or particulars contained
in the original application for registration within five (5) business days of the change.

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 FORM 13
THE INSURANCE ACT, 2018
PART IV- INTERMEDIARIES

PARTICULARS OF APPLICATION

1. Full name of Adjuster: Mr. ; Mrs. ; Ms. ; Dr. OR Full Registered Name of Adjuster:

2. Adress (Home)

(Registered)

3. Telephone Number: (Home) (Work) (Mobile)

(Applicable to Individual only)

4. E-mail address: 5. Nationality:

( For individuals only)

No. 6, applies to Individual Adjusters only.

Instructions for No. 6: Please enclose CPD return and the written verification from the approved educational institution with this
application for renewal of registration. The CPD return must be endorsed by the Agency with which you are employed. If your CPD hours were
pro-rated, enclose evidence to support a pro-ration in accordance with regulation 12(3) of the Regulations

6. (a) Have you met the CPD requirements for the period? Yes No

(b) If No, was a prorated CPD granted? Yes No

(c) If Yes, to (a) above, how many credits were earned? 12 >12

(d ) If more than 12, indicate the number of credits carried forward.1 1 2

( e) Indicate the name of the Approved Educational Institute(s) and the reason for pro rating in accordance with regulation 12(3)
of the Regulations.

( f ) Indicate the CPD points earned in the following areas:

Insurance Business: (Minimum 4 hrs.)
Ethics: (Minimum 4 hrs.)
Laws and Regulations : (Minimum 2 hrs.)
Other2 (Specify): (Minimum 2 hrs.)

Instructions for Nos., 7,8 and 9: Apply to Adjuster Companies only:

7. Has the latest Annual Return for your Adjuster ( Corporate) been filed with the Registrar of Companies? Yes No
If Yes, please provide a certified copy of the Adjuster’s Annual Return.

If No, provide an explanation:

1
Where an Adjuster earns a CPD in excess of the minimum yearly requirement referred to in regulation 12(1) of the Regulations, up to two
of the excess CPD hours may be carried into the following CPD year.
2
In addition to CPD on insurance business, ethics and legislation, Adjusters may undergo CPD in other areas relevant to the business they carry on (e.g.
training on sales and customer relations, new technological developments, etc.).

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 FORM 13
THE INSURANCE ACT, 2018
PART IV- INTERMEDIARIES

PARTICULARS OF APPLICATION

8. Name of the individual Adjuster(s) who will act in the name of and on behalf of the company:

9. Have there been any material changes in the Board of Directors, controlling shareholder or significant shareholder of the Company?
Yes No

If Yes, complete and submit a Personal Questionnaire Declaration Form for the new Director(s) controlling shareholder or significant
shareholder.

Instructions for No. 10 The Managing Director/CEO of the Insurance Adjuster Company and the Secretary of the Adjuster Company must
endorse this application by signing and stamping this form. Appropriate corporate governance mechanisms must be implemented to that
effect, if not already in place.

10. I certify that to the best of my knowledge and belief all of the information given in this application is true and correct.

Imprint Adjuster Company Stamp

Name of Managing Director/CEO of the Adjuster Company:

(Block Letters):

Signature: Date:
(mm/dd/yyyy)
Name of Secretary of the Adjuster Company:

(Block Letters):

Signature: Date:
(mm/dd/yyyy)

Instructions for No. 11: The Insurance Adjuster (Individual) must endorse this application by signing.

11. I certify that to the best of my knowledge and belief all of the information given in this application is true and correct.

Signature: Date:
Insurance Adjuster (Individual) (mm/dd/yyyy)

Name:

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THE INSURANCE ACT, 2018
PART IV- INTERMEDIARIES

PARTICULARS OF APPLICATION

INSURANCE ADJUSTER CHECKLIST (INDIVIDUAL)

SUPPORTING DOCUMENTS: SUBMITTED

1. CPD RETURN
2. PROOF OF PAYMENT OF APPLICABLE FEE ($3,500.00)
3. ALL QUESTIONS ON THE APPLICATION ARE COMPLETED

Signature Date
Insurance Adjuster (Individual) (mm/dd/yyyy)

Name………..…………………………………..

INSURANCE ADJUSTER CHECKLIST (COMPANY)

SUPPORTING DOCUMENTS: SUBMITTED
1. ANNUAL RETURN
2. PROOF OF PAYMENT OF APPLICABLE FEE ($6,500.00)

The Adjuster company verifies that due diligence3 was conducted and all questions on the application form were completed.

Name of Adjuster Applicant:

(Block Letters):

Signature Date
(mm/dd/yyyy)

Name of Managing Director/CEO of the Adjuster Company:

Imprint Adjuster Company Stamp (Block Letters):

Signature Date
(mm/dd/yyyy)

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Due Diligence - the Company confirms that to the best of their knowledge they have conducted the requisite searches and the applicant does not
have any past or pending criminal charges.