Personal Questionnaire and Declaration Supplement
Personal Questionnaire and Declaration Supplement
Personal Questionnaire and Declaration Supplement
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Form PQD/SPQD<strong>Supplement</strong>To be completed by:__________________________________________Name of Licensee(on behalf of Chief Executive Officer, Controllers<strong>and</strong> Officers of Insurance Companies)As at December 31, 200__Name of Chief ExecutiveOfficer, Controller,or Officer(Surname first)Relationship toPosition in CompanyDate of Appointmentto Position…………………………………..Company Stamp <strong>and</strong> Date…………………………………..Corporate Secretary/Director
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