Courtesy translation

ANNEX I

[as referred to in subparagraph a) of article 3 (1)]

QUESTIONNAIRE ON THE SUITABILITY OF THE PERSONS WHO EFFFECTIVELY RUN AND AUDIT THE ENTITY AND PERSONS

RESPONSIBLE FOR KEY FUNCTIONS AND THE RESPONSIBLE ACTUARY1

APPLICANT’S STATEMENT(Person for whom registration is applied for)

I hereby declare, upon my honour, that the information I have provided in this questionnaire is true and is complete, and that in the light of that information I believe I meet the suitability requirements laid down in the law on the taking-up and pursuit of the insurance and reinsurance business, as approved by Law no. 147/2015 of 9 September, and the respective regulatory rules governing the exercise of the function of (identify function) in (identify undertaking)

I further declare that I am aware that the making of false statements is grounds for refusing or revoking registration, in addition to the application of any appropriate criminal penalties.

I promise to inform the Portuguese Insurance and Pension Funds Supervisory Authority, within 15 working days of being aware of them, of all matters likely to affect any of the answers given in this questionnaire.

Date ___ / ___ / _______

___________________________________________(Applicant’s signature)

AUTHORISATION TO PROCESS PERSONAL DATA(Person for whom registration is applied for)

I hereby authorise the Portuguese Insurance and Pension Funds

1 All applicable fields must be completed.

Supervisory Authority to process, the data collected in this questionnaire in order to assess compliance with the legal requirements of registration.

I also authorise the Portuguese Insurance and Pension Funds Supervisory Authority to transmit the data collected in this questionnaire in accordance with the applicable rules on professional confidentiality and the exchange of information.

I further authorise a photocopy of my identification document to be used to confirm my identity before the Portuguese Insurance and Pension Funds Supervisory Authority (to be included only where applicable).

Date ___ / ___ / _______

___________________________________________(Applicant’s signature)

The Portuguese Insurance and Pension Funds Supervisory Authority is responsible for processing the personal data collected through this questionnaire.

Failure to answer certain mandatory questions may preclude a requirement to be deemed as met, whenever compliance is legally required for registration purposes.

Personal data collected shall be held during the time the person concerned exercises the function, plus the time following termination of that function corresponding to the limitation period for criminal proceedings resulting from illegal acts performed during the exercise of the functions. If the procedure results in an initial refusal or subsequent cancellation of the registration, personal data collected shall be held until the legal deadline for the revising of the decision is reached or up to the time of the final court decision, if an appeal is lodged with the courts against a refusal or cancellation.

The provider of the data has the right to access the said data a right that may be exercised in person or in writing, and the right to call for its correction, a right to be exercised pursuant to the procedure laid down in article 7 of Regulatory Rule no. 3/2017-R of 18 May.

UNDERTAKING’S STATEMENT(Insurance or reinsurance undertaking, branch of a third-country

insurance or reinsurance undertaking that pursues business in Portugal, a holding company that is part of an insurance or reinsurance group or a

pension fund managing company)

It is hereby, declared on our honour, that according to the information available to (identify entity),the information provided in this questionnaire is, true and complete and that in the light of that information, (identify entity) believes that (identify person for which registration is applied for) meets the suitability requirements laid down in the law on the taking-up and pursuit of the insurance and reinsurance business, as approved by Law no. 147/2015 of 9 September, and the respective regulatory rules governing the exercise of the function of (identify function) in this entity.

It is further declared that (identify entity) is aware that the making of false statements is grounds for refusing or revoking registration, in addition to the application of any appropriate criminal penalties.

The entity promises to inform the Portuguese Insurance and Pension Funds Supervisory Authority, within 15 working days of being aware of them, of all matters likely to affect any of the answers given in this questionnaire.

Date ___ / ___ / _______

___________________________________________[Signature(s) of the person(s) duly empowered to represent the entity]

Section 1 - Information on the entity where the person to be registered exercises/will exercise functions

1.1 Name      

1.2 Corporate Body Number       Law2      

1.3 ASF registration number      

1.4 Contact person for registration purposesName      Position      Phone number      Email      

Section 2 - Information on nature of application

Initial ApplicationReappointment 3

Registration to exercise new function 3

Registration to exercise function in a different entity 3

Alteration 3

Accumulation of positions or functions 3

Renewal 3

Section 3 - Personal information

▪ Alteration: Yes / No

3.1 Name and contactsFull name      Professional name

     

Sex Escolha um item.Escolha umitem.Date of birth

/ / (day/month/year)

Place of birth Borough       Municipality      

Country      

2 If the entity has already acquired it.

3 Complete only section 3 and the fields containing information relating to information that has changed.

Nationality      Identification document

Type       Number       Expiry date     

Taxpayer number

     

Current place of residence

      (street, nº, floor, location and postcode)

Business address

      (street, nº., floor, location and postcode)

Phone number      Email address      

3.2 I authorise communications from ASF to be made by telephone or email to the contacts given above.

Yes / No

3.3 Additional information:

     

Section 4 – Professional situation

▪ Alteration: Yes / No

4.1 Information on function to be registered

Function:      Date of appointment (day/month/year)

     

Term of office (year/year)      Executive functions: Yes / No Portfolio      Day-to-day management: Yes / No Is the function exercised on behalf of a legal person?

Yes / No If yes, which body?     

Were you appointed as an independent member who will hold the position?

Yes / No

Average number of hours per week expected to be dedicated to the exercise of the function:

     

Relationship with other undertakings where you exercise functions:4

     

4.2 Information on other registrations

4.2.1 Are you registered with any of the following finance sector supervisory bodies?

Yes (state function)

No

The Portuguese Insurance and Pension Funds Supervisory Authority

           

Bank of Portugal            

The Portuguese Securities Market Commission

           

4.2.2 Are you registered with a foreign finance sector supervisory body?Yes / No

If yes, complete the table below:

Name of body Country Function registered                 

                 

                 

4.2.3 Have you ever been registered with a national or foreign finance sector supervisory body?Yes / No

If yes, complete the table below:

Name of body Country Function registered

Duration of registration

                       

                       

                       

4 Where applicable, state the ownership relationship between the entities referred to in the questionnaire (preferably in percentage terms), whenever they belong to the same parent company or have mutual shareholders or partners that have significant influence.

4.3 Professional activities exercised jointly with the activity under consideration:

4.3.1 Professional activity registered with the Portuguese Insurance and Pension Funds Supervisory Authority, the Bank of Portugal or the Portuguese Securities Market Commission, that will be exercised jointly with the activity under consideration:

Entity

Branch of business

Function

Date of appointment(day/month/year)

Term of office (year/year)

Day-to-day functions or executive management functions

Average number of hours per week dedicated to the exercise of the function

Relationship with other entities where functions are exercised

Supervisory body

     

     

                  Escolha um item.

Escolhaumitem.     

           

     

     

                  Escolha um item.

Escolhaumitem.     

           

     

     

                  Escolha um item.

Escolhaumitem.     

           

4.3.2 Professional activity not requiring registration with the Portuguese Insurance and Pension Funds Supervisory Authority, the Bank of Portugal or the Portuguese Securities Market Commission, that will be exercised jointly with the activity under consideration:

Entity

Branch of business

Function

Date of appointment(day/month/year)

Term of office(year/year)

Day-to-day functions or executive

Average number of hours per

Relationship with other entities where

Supervisory body

management functions

week dedicated to the exercise of the function

functions are exercised

     

     

                  Escolha um item.

Escolhaumitem.     

           

     

     

                  Escolha um item.

Escolhaumitem.     

           

     

     

                  Escolha um item.

Escolhaumitem.     

           

4.4 Additional information:

     

Section 5 – Qualifications and professional experience 5

▪ Alteration: Yes / No

5.1 Academic qualifications and vocational training

Educational or vocational training

establishment

Academic or vocational field

Level Year awarded Length of course

                                                                                                                   

5 This section does not have to be completed when the function is that of responsible actuary.

                                              

5.2 Details of professional experience over the last 10 years, identifying, at least, all entities where functions were exercised and the functions exercised or posts held.

Entity Branch of business

Function/position

Date of appointment(day/month/year)

Term of office(year/year)

Main responsibilities

Supervisory body

                                         

                                         

                                         

5.3 Additional information:

     

Section 6 – Good repute

▪ Alteration: Yes / No

If you answer yes to any of the questions below, please provide the following information:a) The events which motivated the opening of proceedings;b) The type of crime or illegal act; c) The date of the conviction; d) The judgement or penalty; e) The court or other body that ordered the judgement or levied the penalty; f) The court or other body where the proceedings are underway, the stage or the outcome; g) The name of the companies involved in the bankruptcy, administration or winding-up proceedings; h) The type of control exercised or the qualifying holding held;i) The functions exercised; j) The name of the supervisory body that conducted the previous evaluation of your good repute (together with the written record of the outcome of that evaluation);k) The grounds for the refusal, revoking, cancellation or termination of the registration, authorisation, acceptance or licence or disqualification in regards to a commercial, business or professional activity;

l) The reasons underlying the dismissal, termination of contract, removal or disciplinary procedure;m) The grounds for the ban on being a director or manager of a civil or trading company or from performing functions for one;n) The grounds for opposing the acquiring or retaining of a holding; and o) If deemed relevant, your view point as to the facts of the matter.

When replying to questions 6.1, 6.2, 6.3 and 6.4 simply indicate the civil proceedings that have had or may have a significant impact on the financial soundness of the person concerned.

6.1 Have you ever been found guilty, in Portugal or abroad, in civil or criminal proceedings?

Yes / No

     

6.2 Has an undertaking ever been found guilty, in Portugal or abroad, in civil or criminal proceedings, for actions taken while you were a director, department head or manager, in law or in fact, or while it was controlled by you?

Yes / No

     

6.3 Are or have there ever been civil or criminal proceedings against you in any court in Portugal or abroad?

Yes / No

     

6.4 Are or have there ever been civil or criminal proceedings, in any court in Portugal or abroad, against an undertaking for actions taken while you were a director, department head or manager, in law or in fact, or while it was controlled by you?

Yes / No

     

6.5 Have you ever been found guilty, in Portugal or abroad, in administrative proceedings for acts relating to the pursuit of business in the financial field?

Yes / No

     

6.6. Has an undertaking ever been found guilty, in Portugal or abroad, in administrative proceedings for acts relating to the pursuit of business in the financial field while you were a director, department head or manager, in law or in fact, or while it was controlled by you?

Yes / No

     

6.7 Are or have there ever been administrative proceedings, in Portugal or abroad, against you for acts relating to the pursuit of business in the financial field?

Yes / No

     

6.8 Are or have there ever been administrative proceedings, in Portugal or abroad, against an undertaking for actions taken while you were a director, department head or manager, in law or in fact, or while it was controlled by you?

Yes / No

     

6.9 Have you ever been found guilty, in Portugal or abroad, of breaching rules or regulations governing the business of insurance or reinsurance undertakings, pension fund managing companies, credit institutions, finance companies or financial institutions, the securities market, and insurance or reinsurance brokerage?

Yes / No

     6.10 Has an undertaking ever been found guilty, in Portugal or abroad, of breaching rules or regulations governing the business of insurance or reinsurance undertakings, pension fund managing companies, credit institutions, finance companies or financial institutions, the securities market, and insurance or reinsurance brokerage, for actions taken while you were a director, department head or manager, in law or in fact, or while it was controlled by you?

Yes / No

     

6.11 Are or have there ever been any proceedings, in Portugal or abroad, against you for breaching rules or regulations governing the business of

insurance or reinsurance undertakings, pension fund managing companies, credit institutions, finance companies or financial institutions, the securities market, and insurance or reinsurance brokerage?

Yes / No

     

6.12 Are or have there ever been proceedings, in Portugal or abroad, for breaching rules or regulations governing the business of insurance or reinsurance undertakings, pension fund managing companies, credit institutions, finance companies or financial institutions, the securities market, and insurance or reinsurance brokerage, against an undertaking for actions taken while you were a director, department head or manager, in law or in fact, or while it was controlled by you?

Yes / No

     

6.13 Have you ever been declared bankrupt, in Portugal or abroad?

Yes / No

     

6.14 Has an undertaking of which you have been a director, department head or manager, in law or in fact, or while it was controlled by you or while you held a qualifying holding ever been declared bankrupt or subject to administration, bankruptcy or winding-up proceedings?

Yes / No

     

6.15 Are you currently the subject of bankruptcy proceedings, in Portugal or abroad?

Yes / No

     

6.16 Is an undertaking of which you are a director, department head or manager, in law or in fact, or which is controlled by you or in which you hold a qualifying holding currently subject to administration, bankruptcy or winding-up proceedings, in Portugal or abroad?

Yes / No

     

6.17. Have you ever been dismissed, had your contract terminated or been removed from a position that requires a special relationship of trust?

Yes / No

     

6.18 Have you ever been penalised for a breach of the disciplinary rules, ethical rules or code of conduct applying to an occupation?

Yes / No

     

6.19 Has your registration, with the appropriate supervisory body, for the exercise of functions at a credit institution, finance company or financial institution, insurance or reinsurance undertaking, insurance or reinsurance brokerage or pension fund managing company, ever been refused, cancelled or revoked, in Portugal or abroad?

Yes / No

     

6.20 Has a supervisory body, in Portugal or abroad, ever evaluated your good repute for the purposes of exercising functions at a credit institution, finance company or financial institution, insurance or reinsurance undertaking, insurance or reinsurance brokerage or pension fund managing company?

Yes / No

     

6.21 Has a supervisory body of a non-financial sector, in Portugal or abroad, ever evaluated your good repute?

Yes / No

     

6.22 Have you ever been the subject of the refusal, revoking, cancellation or termination of the registration, authorisation, acceptance or licence in regards to a commercial, business or professional activity, by a supervisory body, a professional body or similar entity, or have you ever been disqualified from holding a position in a public body?

Yes / No

     

6.23 Has a supervisory body, in Portugal or abroad, ever stated its opposition to you acquiring or retaining a holding in a civil or trading company?

Yes / No

     

6.24 Have you ever been banned, in Portugal or abroad, from exercising the functions of a director or manager of a civil or trading company or performing functions in it by the courts, a supervisory body or by a professional body or similar entity?

Yes / No

     

6.25 Have you ever been included, in Portugal or abroad, in default notices in the Central Credit Register or any other registers of a similar nature?

Yes / No

     

6.26 Have you ever, in Portugal or abroad, been dismissed as the member of the board of directors of any trading company by the courts or seen the courts confirm your dismissal with due cause?

Yes / No

     

6.27 Have you ever been ordered to pay damages to a trading company, to its shareholders, creditors or third parties while you were a director, department head or manager in Portugal or abroad?

Yes / No

     

If you are exercising the function on behalf of a legal person, please repeat the answers to questions 6.1 to 6.27 from the legal person’s standpoint.

Section 7 – Independence and conflicts of interest6

7.1 Are you associated with any specific interest group within the entity or in a situation that is likely to jeopardise impartial analysis and decision making?

Yes / No

Please specify.      

7.2 Do you exercise, or have you exercised in the last three years, functions as a member of a governing body of the entity in which you are going to exercise the function subject to registration, of a controlling or group entity or of a rival entity?

Yes / No

Please specify.      

7.3 Do you have, or have you had in the last three years, either directly or indirectly, any contractual or significant commercial relationship with the entity in which you are going to exercise the function subject to registration, with a controlling or group entity or with a rival entity?

Yes / No

Please specify.      

7.4 Do you hold or act on behalf of the holder of share capital in the entity in which you are going to exercise the function subject to registration, in a controlling or group entity or in a rival entity?

Yes / No

Please specify.      

7.5 Do you have, or have you had in the last three years, a professional or economic relationship with members of the board of directors or the audit body of the entity in which you are going to exercise the function subject to registration, of a controlling or group entity or of a rival entity?

Yes / No

Please specify.      

6 Only to be completed when the registration relates to a position on the board of directors or the audit body, or to the function of statutory auditor or responsible actuary.

7.6 Do you have, or have you had in the last three years, a professional or economic relationship with the owner of a shareholding in the entity in which you are going to exercise the function subject to registration, in a controlling group entity or in a rival entity?

Yes / No

Please specify.      

7.7 Have you been re-elected for more than two terms of office, consecutive or otherwise?

Yes / No / Not applicable

7.8 Do you benefit from any specific advantages from the entity?

Yes / No

Please specify.      

7.9 Do you exercise functions in a rival entity, do you act on its behalf, or are you bound in any other way to the interests of a rival company?

Yes / No

Please specify.      

7.10 Are you the spouse, partner, direct relative or a collateral relative up to the third degree of a person who is in one of the situations described in points 7.2 to 7.4, 7.8 or 7.9?

Yes / No

Please specify.      

If you are exercising the function on behalf of a legal person, please repeat the answers to questions 7.1 to 7.9 from the legal person’s standpoint.

Section 8 – Means available7/8

7 To be completed only when the registration relates to the function of statutory auditor or the function of responsible actuary.

8 If the statutory auditor exercises the function on behalf of an audit firm or the responsible actuary acts as part of an audit firm, please state that firm’s means.

8.1 Information on the human resources available to exercise the function to be registered.

Function Academic or professional qualifications

Type of contract Exclusivity basis

                       

8.2 Technical and material resources available to exercise the function to be registered.

     

8.3 Do you have compulsory third party liability insurance to cover damage caused when exercising the function to be registered?

Yes / No

Please specify the insurer and the minimum insured capital.      

Section 9 - Additional information or further clarifications