1782
THE NEW ZEALAND GAZETTE.
[No. 83

SCHEDULE B.

Receipts during the Year.

Fire.
Marine.
Total.

£ s. d.
£ s. d.
£ s. d.

1. Gross cash premiums received .. .. .. ..

2. Less reinsurance, rebates, &c. .. .. .. ..

3. Net cash receipts for premiums .. .. .. ..

4. Received for interest, dividends, and rent .. .. .. ..

5. Received from all other sources .. .. .. ..

Disbursements during the Year.

1. Gross amount paid for losses .. .. .. ..

2. Less salvages and reinsurances.. .. .. ..

3. Net amount paid for losses .. .. .. ..

4. Commissions and brokerage .. .. .. ..

5. Expenses of management .. .. .. ..

6. Dividends paid .. .. .. ..

7. Taxes paid .. .. .. ..

8. All other disbursements .. .. .. ..

SCHEDULE C.
Miscellaneous.

Fire.
Marine.
Total.

£ s. d.
£ s. d.
£ s. d.

Amount of risks in force at beginning of year .. .. ..
Add amount of risks underwritten and renewed during the year ..

Total .. .. .. ..

Deduct expirations and cancellations .. .. .. ..

In force on .. .. .. ..
Deduct amount reinsured .. .. .. ..

Net amount in force .. .. .. ..

Amounts deposited in various countries for the protection of policyholders,
as follows: [Here give amount for each country, state, colony, &c.]

Total .. .. .. ..

Date of organization of company:
Location of head office of company:
Location of principal office in New Zealand of company:
Name in full of attorney in New Zealand of company:
Is such attorney authorised to sue and capable of being sued on behalf of company in New Zealand?

SCHEDULE D.
Business in New Zealand.

Fire.
Marine.
Total.

£ s. d.
£ s. d.
£ s. d.

Loans outstanding at close of year .. .. .. ..
House and landed property owned in the colony at close of year ..
All other assets, consisting of Government securities of the colony and
securities realisable in the colony, at close of year ..
Amount of risks underwritten or insurances in force at close of year ..
Amount of premiums received during the year .. .. ..
Amount of losses paid during the year .. .. ..
Amount of losses incurred during the year .. .. ..
All other liabilities at close of year .. .. ..

I, [name], of [address], as and being the [official position held in company] of the Company, do solemnly and
sincerely declare that the above is a true statement of the affairs of the said company as on the day of
, 18. And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions
of an Act of the General Assembly of New Zealand intituled "The Justices of the Peace Act, 1882."

Declared at , this day of , 18, before me—
, Justice of the Peace [or Solicitor, or Notary Public].

SCHEDULE E.
Certificate of the Public Trustee under the Provisions of "The Foreign Insurance Companies' Deposits Act,
1894," and "The Foreign Insurance Companies' Deposits Amendment Act, 1895."

Whereas the [full name of company] has, in pursuance of the above-mentioned Acts, furnished to the Public Trustee a
statement of its affairs for the period and in the form prescribed in pursuance of the said Acts: Now, in pursuance of
and compliance with the provisions of the said Acts, the Public Trustee doth hereby grant his certificate authorising the
said [full name of company] to carry on the business of for the period of twelve months from the
As witness the hand of , the Public Trustee, and his seal of office, this day of , 189.