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PRIVATE AND CONFIDENTIALForm PQDINSURANCE ACT, CHAPTER 84:01FINANCIAL INSTITUTIONS ACT, 2008CENTRAL BANK ACT, CHAPTER 79:02EXCHANGE CONTROL ACT CHAP 79:50FINANCIAL OBLIGATIONS REGULATIONS, 2010 (as amended)PERSONAL QUESTIONNAIRE AND DECLARATION(of Controller, Controlling Shareholder, Significant Shareholder, Acquirer,Director, Principal Representative, Officer including Compliance Officer andAlternate Compliance Officer (as applicable), Actuary, Agent, Adjuster, Brokerand Sales Representative)1.Name of regulated entity or proposedregulated entity for which the questionnaire isbeing completed.2.(a) Please state in what capacity or proposedcapacity you are completing thisquestionnaire. (Indicate Job Title)(a)(b) Effective date (DD/MM/YYYY)(b)SECTION 1- PERSONAL DETAILS3.4.(a) Surname of person making declaration(a)(b) Forename(s)(b)(c) Name of Spouse (including maiden name)(c)(d) Any name(s) by which you or your spousehave previously been known.(d)(a) Private Residential Address in Trinidadand Tobago(b) Private Overseas Residential Address ifresiding abroadPage 1 of 15

5.Previous private address(es) during the lastten years (with relevant dates).6.(a) Date of Birth (dd/mm/yyyy)(a)(b) Place of Birth (including town, state andcountry)(b)(a) Nationality(a)7.(b) How acquired (e.g. birth, naturalisation,marriage etc.)(b)(c) If not a national of Trinidad and Tobago,please indicate passport number and countryof issue.(c)(d) Does the applicant require a work permit tolegally work in Trinidad and Tobago?(d)(e) If answer to (d) is Yes, has one beenapplied for / acquired?(e)SECTION 2 - EMPLOYMENT DETAILS8.(a) Present occupation or employment(Position; Name of Employer; Job Title;Effective date). Please give date of originalappointment to this present position and dateof last reappointment where applicable.(dd/mm/yyyy)(a)(b) Occupation and employment during thelast ten years, including:i.the name(s) of employer(s)ii.the nature of the business(es);iii.position(s) held and relevant date(s)iv.the name of any regulatorybody/authority which may haveregulated the employer(s).(b)Please note that ALL gaps in employment forthree months or longer must be accounted for.(c)Use Appendix 1 if space provided here isinadequate.Page 2 of 15

EDUCATION & TRAINING9.(a) Give details of Education and Professionalqualifications and affiliations and year(s) inwhich they were obtained.(a)(b) Membership in professional bodies (pastand present)(b)(c) Confirmation of compliance status withContinuingProfessionalDevelopment1requirements of the professional bodiesreferred to in (b) above, if applicable(c)Use Appendix 2 if space provided here isinadequate.DIRECTORSHIPSwhat companies2, partnershipsunincorporatedassociationsarecurrently a director?10. OfandyouPlease list each directorship currently heldstating date of appointment.Use Appendix 3 if space provided here isinadequate.11. Ofwhat companies, partnerships andunincorporated associations have you been,at any time during the last ten years, adirector?Please list each directorship that was heldstating date of appointment and date oftermination of appointment or when youceased to hold that position.Use Appendix 4 if space provided here isinadequate.1This requirement is applicable to insurance Agents, Adjusters, Brokers and Sales Representatives.Companies throughout this document refers to both private and public companies inclusive of entitiesestablished via statute as well as statutory boards, statutory corporations and state enterprises2Page 3 of 15

CURRENT SHAREHOLDINGS12. Please indicate the names and number ofshares held for companies, partnerships andunincorporated associations, where 10% ormore shareholding is currently held.In all cases please specify: the number of shares or stockheld; the percentage ownership of theentity which this represents; whether the shares or stock areheld beneficially or otherwise; and the country of incorporation of theentity.Use Appendix 5 if the space provided hereis inadequate.PAST SHAREHOLDINGS13. Ofwhat companies, partnerships andunincorporatedassociationshaveyoupreviously been, at any time during the lastten years, a controlling shareholder,significant shareholder, or acquirer?In each case state the number of shares orstocks held and the percentage ownershipsuch membership represented.Please specify the country of incorporationand relevant commencement and terminationdates (dd/mm/yyyy) in each case.Use Appendix 6 if the space provided hereis inadequate.REPUTATION, CHARACTER & FINANCIAL INTEGRITY14. Have you, anywhere, ever been suspended,dismissed, asked to resign from any office oremployment or barred from entry to anyprofession or occupation including anyfiduciary office or position of trust?If so, please provide details including relevantdates.15. Have you, anywhere, ever been the subject ofany proceedings of a disciplinary or criminalnature or been notified of any impendingproceedings or investigations which may leadto such proceedings?Page 4 of 15

If so, please provide details including relevantdates.16. Have you anywhere ever been the subject ofan investigation into any suspicious financialactivities from any office or employment?If so, please provide details, includingrelevant timeframe and conclusions of theinvestigation.17. Have you, anywhere, ever been censured,subject to any proceedings of a disciplinarynature or criticized by any professional bodyto which you belong or belonged and haveyou ever held a practicing certificate subject toconditions?If so, give full particulars including relevantdates.18. Have you ever been adjudicated bankrupt bya court in any jurisdiction?If so, give full particulars including relevantdates.19. Have you failed to satisfy any debt adjudgeddue and payable by you as a judgementdebtor under an order of a court in anyjurisdiction?If so, give full particulars of the sums anddates of all judgement debts or awards,whether satisfied or not, and the total numberof all judgment debts or awards.20. Has a loan or credit facility (or part thereof)extended to you by any financial or lendinginstitution at any time during the last tenyears, been restructured, renegotiated,provide against or been the subject of a writeoff or debt forgiveness for reasons of nonpayment by you?If so, give full particulars of the sums anddates, the circumstances surrounding theaction and the current status.21. Have you at any time in Trinidad and Tobagoor in any other jurisdiction(a) been convicted by a court for an offenceinvolving fraud, dishonesty, a financial crimeincluding money laundering or terrorismfinancing;(b) been convicted of any offence (other than(i) an offence committed when you were underthe age of 18 unless the offence wascommitted within the last ten years, or (ii) anPage 5 of 15

offence in connection with the use orownership of a motor vehicle which was triedin a court of summary jurisdiction); or(c) been deemed as not ‘fit and proper” by anyregulatory authority?If so, give full particulars of the court by whichyou were convicted, the offence and date ofconviction, and the penalty imposed.If deemed not “fit and proper”, indicate theregulatory authority, the entity to which thisrelated and the date of the assessment.22. Have you at any time been summonsed,charged or otherwise investigated in anyjurisdiction, for an offence involving fraud,dishonesty, a financial crime including moneylaundering or terrorism financing or violence?If so, give full particulars of the offence andstatus of court proceedings including relevantdates.23. Have you or any company, partnership orunincorporated association with which youare, or have been associated as a lder, acquirer or officer, been thesubject of an investigation, anywhere, by agovernmental, professional or other regulatorybody?If so, give full particulars including relevantdates.24. Have you at any time been investigated,disciplined, suspended or reprimanded by aregulatory or professional body, a court ortribunal, whether publicly or privately inrelation to any business in which you have acontrolling or significant interest or exercisesignificant influence?If so, give full particulars including relevantdates.25. Have you, in connection with the formation,control or management of any body corporate,partnership or unincorporated institution beenadjudged by a court, in any jurisdiction, civillyliable for any fraud, misfeasance or othermisconduct by you towards such a body orcompany or towards any members thereof?If so, give full particulars including relevantdates.26. Haveyou been a director, controllingshareholder, significant shareholder, acquireror officer of any body corporate, partnership orPage 6 of 15

unincorporated institution anywhere, at thetime of or within the ten years immediatelypreceding a winding up order made by acourt against the said institution?If so, give full particulars including relevantdates.27. Haveyou been a director, controllingshareholder, significant shareholder, acquireror officer of a company anywhere that wasplaced into receivership while you wereassociated with it or within ten yearsimmediately preceding the receivership?If so, give full particulars including relevantdates.28. Haveyou been a director, controllingshareholder, significant shareholder, acquireror officer of a former licensee whose licensewas revoked while you were associated with itor within the ten years immediatelypreceding such license being revoked unlesssuch revocation was due to (i) amalgamationwith another licensed institution or company or(ii) its voluntary winding-up?If so, give full particulars including relevantdates.29. Has any body, partnership or unincorporatedinstitution with which you were associated asa director, controlling shareholder, significantshareholder, acquirer or officer, anywhere,made any compromise or arrangement with itscreditors or ceased trading in circumstanceswhere its creditors did not receive or have notyet received full settlement of their claims,either while you were associated with it orwithin one year after you ceased to beassociated with it?If so, give full particulars including relevantdates.30. In carrying out your duties will you be actingon the directions or instructions of any otherperson?If so, give full particulars.CONFLICTS OF INTEREST31. Have you or a relative any professional orcommercial relationships or interests or haveyou had any such relationship over the past 3years with the financial institution, its parent orany of its affiliates or subsidiaries?Page 7 of 15

If so, provide full particulars including relevantdates.32. Have you or a relative any professional orcommercial relationship or interests or haveyou had such relationship over the past 3years with competitors or clients of thefinancial institution; its parent or any of itsaffiliates or subsidiaries?If so, provide full particulars including relevantdates.I, .,NAME IN BLOCK CAPITALScertify that the above information is complete and correct to the best of my knowledge andbelief and I undertake that as long as I continue to be a director, officer, controllingshareholder, significant shareholder, acquirer, agent, broker, sales representative, orbroker of an institution regulated by the Central Bank of Trinidad and Tobago, I will notifythe Central Bank of any material changes to the answers given to questions 1 to 32 abovewithin a period of thirty days of the change. I also confirm that I have provided all of therequired documentation indicated at Appendix 7.I further declare that I am fully aware that the submission of false or misleading informationor withholding information may render me unfit, and may result in my being disbarred fromacting in the position indicated in this questionnaire or in any position for which a PQD issubmitted on my behalf in the future. .Date (dd/mm/yyyy).Signature of PersonMaking DeclarationWitnessed and signed in the presence of .BLOCK CAPITALS .Date (dd/mm/yyyy) .Signature(Corporate Secretary/ CEO)Company StampPage 8 of 15