I hereby apply for an intermediary’s licence under the Insurance Act, 2006 and declare the above particulars to be true. I agree to notify the National Insurance Commission of any material alteration in the information supplied above and that:

• a) I have not been adjudged insolvent or bankrupt.
• b) I have not made any assignment or an arrangement or composition with creditors which has been rescinded or set aside.
• c) I have not been convicted by a court of law in any country of an offence involving dishonesty, fraud or gross misconduct nor had to appeal to any conviction under terms of any enactment in Ghana or any other country.