Personal Questionnaire and Declaration (PQD) - Central Bank of ...

PRIVATE AND CONFIDENTIALForm PQDINSURANCE ACT Chapter 84:01PERSONAL QUESTIONNAIRE AND DECLARATION FORM(Salesmen and Agents of Insurance Companies)1. Name and address of Insurance Company.2. (a) Surname of person making declaration.(b) Forename(s).(c) Spouse’s full name (including maidenname).(d) Any name(s) by which you and yourspouse have previously been known.(a)(b)(c)(d)3. Are you completing this questionnaire as aSalesman or Agent?4. Private Residential Address.5. Previous private addresses during the last tenyears (with relevant dates).6. (a) Date of Birth (DD/MM/YY).(b) Place of Birth.(a)(b)N.B: Please respond to all questions. This form will be returned if declarants do not respondto all questions. If insufficient space is provided, please attach extension sheet(s).1

PRIVATE AND CONFIDENTIALForm PQD7. (a) Nationality.(b) How acquired? (e.g. birth, naturalisation,marriage).(a)(b)8. (a) State your complete official job title,and date of original appointment to thispresent position (not date of lastreappointment). Name of Agency andaddress of Agency, if applicable.(b) Occupation and employment duringthe last ten years, including the names ofemployers, the nature of the businesses,positions held and relevant dates.(a)(b)Use Appendix PQD/Q8 (attached) ifspace provided here is inadequate.9. Have you at any time been charged with orconvicted of any offence or otherwise foundliable by a Civil, Criminal or Military Court(excluding minor road traffic offences)whether in Trinidad and Tobago orelsewhere?If so, give details of charge, and if convicted,the date of conviction and full particulars ofthe offence (including any offences takeninto consideration) and the penalty imposed.10.(a) Have you, anywhere, ever beencensured, disciplined or criticised by anyprofessional body to which you belongor belonged?Give full particulars.(a) Have you ever held a practicingcertificate subject to conditions?Give full particulars.(a)(b)2

PRIVATE AND CONFIDENTIALForm PQD11.Have you, anywhere, ever been dismissedfrom any office or employment, asked toresign from any office employment, orbarred from entry to any profession oroccupation? If so, give full particularsincluding allegations of fraudulent activitymade against you.12. Have you been adjudicated bankrupt by acourt in any jurisdiction? If so, give fullparticulars.13. Have you failed to satisfy any debtadjudged due and payable by you as ajudgement-debtor under an order of acourt in any jurisdiction? If so, give fullparticulars.I, .................................................................................................................................................………………BLOCK CAPITALScertify that the above information is complete and correct to the best of my knowledge and belief and Iundertake that as long as I continue to be a Salesman or Agent registered under the Insurance Act: Chapter84:01, I will notify the Central Bank of Trinidad and Tobago of any material changes affecting thecompleteness of the answers to questions 1 to 13 above............................................... ..................................................................Date (DD/MM/YY)Signature of Person making declarationPlease submit the following documents along with this declaration:- a valid Certificate of Character issued by the Trinidad and Tobago Police Service.- a photocopy of your ‘photo ID’: Trinidad and Tobago National Identification Card (front and back),Driver’s Permit or passport (bio-data page).3

PQD/Q8Declarant’s Occupation and Employment during the Last 10 YearsName of Declarant’s EmployerDeclarant’s Official Job Title Commencement and TerminationDates of EmploymentNature of Business of Employer4