I declare the above particulars to be true and correct and agree to notify the Authority of any material alteration in the information supplied and in terms of any law in force in Uganda.

I further declare that I-

1. Have not been adjudged bankrupt;
2. Have not compounded with creditors;
3. Have not been convicted by a court in any country of any offence involving fraud or dishonesty or misconduct.
4. Am not a civil servant or municipal employee;
5. Am not an administrator, director, auditor or employee of any insurance company or broking company or any institution regulated by the Financial InstitutionsAct, (Cap 54) Laws of Uganda, 2002)
6. Am not a risk inspector nor loss adjuster nor insurance valuer.