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APPLICATION FORM: TRANSITIONAL EXEMPTION FROM A SECTION(S) IN
BOARD NOTICE 158 OF 20141
General instructions:
The application form must be completed with reference to the applicable Legal and Policy Framework that appears
at the end of the application form.
PART 1: GENERAL INFORMATION
Insurer Name
<insname>
Insurer Number
<insnum>
</insname>
</insnum>
Type of application (please indicate with “x” for all the questions in the spaces
provided below):
Application under the -
PART 2: TRANSITIONAL EXEMPTIONS
Exemption
[Insurers are required to complete the table below, with a separate row used for each aspect from which exemption
is sought]
Section from
Reason for requiring exemption
Proposed Date
Key Actions (with
which
(explain why the practicalities
for compliance
expected completion
exemption is
require progressive application
sought
of the specific section)
<section1>
replace
this with the
<reason1>
delete this text and replace
with the reason
</reason1>
dates in brackets)
<date1>
dd/mm/yyyy</date1>

appropriate

numbers (e.g.

10(1))
replace
this with the
<reason2>
delete this text and replace
with the reason
</reason2>
<date2>
dd/mm/yyyy</date2>
<actions2>

appropriate

numbers (e.g.

10(1))
Action 1 (mmm
yy)
Action 2 (mmm
yy
etc</actions1>
</section1>
<section2>
Action 1 (mmm
yy)
Action 2 (mmm
yy
etc</actions2>
</section2>
<section3 replace
<reason3>
delete this text and replace
<date3>
dd/mm/yyyy</date3>
1
<actions1>
<actions3>

Action 1 (mmm
Published in Government Gazette No. 38357 on 19 December 2014 in terms of section 12(1)(bD) of the Shortterm Insurance Act No. 53 of 1998 and Long-term Insurance Act No. 52 of 1998.
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this with the
with the reason
</reason3>
appropriate

numbers (e.g.

10(1))
</section3>
<section4>
replace
this with the
<reason4>
delete this text and replace
with the reason
</reason4>
<date4>
dd/mm/yyyy</date4>
<actions4>

appropriate

numbers (e.g.

10(1))
Action 1 (mmm
yy)
Action 2 (mmm
yy
etc</actions4>
</section4>
<section5>
replace
this with the
<reason5>
delete this text and replace
with the reason
</reason5>
<date5>
dd/mm/yyyy</date5>
<actions5>

appropriate

numbers (e.g.

10(1))
yy)
Action 2 (mmm
yy
etc</actions3>
</section5>
Action 1 (mmm
yy)
Action 2 (mmm
yy
etc</actions5>
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PART 3: CONTACT DETAILS & CONFIRMATION
Instructions:
Please provide the details of the responsible person / public officer to whom the Registrar must direct all
correspondence.
Full name and surname
<contactname>
</contactname>
Telephone number
<contactnum>
E-mail address
<contactemail>
</contactnum>
</contactemail>
I, ……………………………………………………………………………………………….. [full name of responsible person /
public officer], identity / passport number
<contactid>
</contactid>
hereby certify, to the best of my knowledge, that the
answers and information are complete, accurate, true and not misleading in any respect.
………………………………………………………….
Signature of responsible person / public officer
…………………….
Date
We hereby confirm that this application and all information contained herein represent the views and express intentions of the
board and audit committee.
………………………………..
Signature of chairperson of the board
…………………….
Date
………………………………..
Signature of CEO
…………………….
Date
………………………………..
Signature of chairperson of the audit committee
…………………….
Date
………………………………..
Signature of chairperson of the risk committee
…………………….
Date
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INFORMATION RELATING TO AN APPLICATION FOR TRANSITIONAL EXEMPTION FROM A
SECTION(S) IN BOARD NOTICE 158 OF 2014
A.
Introduction
This application form relates to an application for transitional exemption from a section(s) in Board Notice 158 of
2014.
B.
Interpretation/Legal framework
1.
In the application form any word or expression defined in the Long-term Insurance Act, the Short-term
Insurance Act or Board Notice 158 of 2015 (published in Government Gazette No. 38357 on 19 December
2014 in terms of section 12(1)(bD) of the Short-term Insurance Act No. 53 of 1998 and Long-term
Insurance Act No. 52 of 1998), as the case may be, including any measure referred to in the definitions of
“this Act” in sections 1(1) of the Acts, have, unless the context otherwise indicates, the meaning so
defined.
Note that, if there is any discrepancy between the application form and the provisions of the Long-term
Insurance Act, the Short-term Insurance Act or Board Notice 158 of 2015, as the case may be, the
provisions in the Act or the Board Notice will be deemed correct.
In terms of section 30 of Board Notice 158 of 2014 an insurer may, where practicalities require the
progressive application of a specific section of Board Notice 158 of 2014, apply for an exemption from that
specific section for a specific period on specific conditions. To apply for such an exemption, the insurer is
required to complete the table in Part 1 of this application form, with a separate row used for each aspect
from which exemption is sought.
2.
3.
C.
Instructions
1.
5.
The application must be submitted directly to the Registrar of Long-term Insurance or Short-term Insurance
at the Financial Services Board.
Applications will only be processed if submitted via the FSB Insurance Upload Facility on the web site and
both the typed word version as well as a scanned, signed copy are submitted.
The application form must be completed in full by the responsible person and be signed by the person duly
authorised to sign this form.
The application form must be completed with reference to the instructions provided in the application form
and this information document in respect of each part of this form.
The format of the application form or the wording of questions may not be changed.
D.
Additional Information
2.
3.
4.
The Registrar, in accordance with section 4(2) of the Long-term Insurance Act and Short-term Insurance Act,
may request additional information relating to the application.