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					Rev. 7/2008



                                     STATEMENT OF ASSETS AND LIABILITIES PURSUANT TO

                       SECTION 25A AS AT                                              (financial year end date)


 Name of Insurer :
A. Assets maintained in Hong Kong
                                                            Items                                                      $
 Land and buildings*                                                                                              01       0
                         Issued by, or guaranteed by, any government or public authority                          02       0
 Fixed interest          Other fixed interest
                                                       listed                                                     03       0
                         securities except
 securities*
                         those in associated or
                                                       unlisted                                                   04       0
                         subsidiary companies
 Variable interest       Issued by, or guaranteed by, any government or public authority                          05       0
 securities*             Others                                                                                   06       0
                         Equity shares except          listed                                                     07       0
   Other variable        those in associated or
      interest           subsidiary companies          unlisted                                                   08       0
   investments*
                         Holdings in unit trusts                                                                  09       0
                                                                                           listed                 10       0
                                                       Value of any shares held
                                                                                           unlisted               11       0
                         Insurers                      Debts (other than debts             secured                12       0
 Investment in                                         which must be included              partly secured         13       0
 associated or                                         in line 20 or 21 to 28)             unsecured              14       0
 subsidiary                                                                                listed                 15       0
 companies*                                            Value of any shares held
                                                                                           unlisted               16       0
                         Non-insurers                  Debts (other than debts             secured                17       0
                                                       which must be included              partly secured         18       0
                                                       in line 20 or 21 to 28)             unsecured              19       0
 Loans secured by contracts of insurance issued by the insurer                                                    20       0
                                                       Premium income in respect of direct insurance
                                                       but not yet paid to the insurer less commission            21       0
                                                       payable thereon

                                                       Amounts due from ceding insurers and inter-
                                                                                                                  22       0
                                                       mediaries under reinsurance contracts accepted
                         Due from associated or
                         subsidiary companies          Amounts due from reinsurers and intermediaries
                                                       under reinsurance contracts ceded (excluding               23       0
                                                       recoveries in respect of outstanding claims)
                                                       Recoveries due by way of salvage or from other
                                                       insurers in respect of claims paid other than              24       0
 Insurance                                             recoveries under reinsurance contracts ceded
 debts                                                 Premium income in respect of direct insurance
                                                       but not yet paid to the insurer less commission            25       0
                                                       payable thereon

                                                       Amounts due from ceding insurers and inter-
                                                                                                                  26       0
                                                       mediaries under reinsurance contracts accepted
                         Due from others
                                                       Amounts due from reinsurers and intermediaries
                                                       under reinsurance contracts ceded (excluding               27       0
                                                       recoveries in respect of outstanding claims)
                                                       Recoveries due by way of salvage or from other
                                                       insurers in respect of claims paid other than              28       0
                                                       recoveries under reinsurance contracts ceded
  Debts not                 Fully secured                                                                       29                        0
  previously                Partly secured                                                                      30                        0
  covered*                  Unsecured                                                                           31                        0
                                                            Fixed term deposits                                 32                        0
                            With banks
                                                            Current accounts                                    33                        0
  Deposits and
                            With restricted
  current accounts*                                         Fixed term                                          34                        0
                            licence banks and
                            deposit-taking
                                                            At call                                             35                        0
                            companies
  Cash                                                                                                          36                        0
  Computer equipment, office machinery, furniture, motor vehicles and other equipment                           37                        0
  Other assets, to be separately specified if material                                                          38                        0
  Total                                                                                                         39                        0
  Letter of credit or other commitment from banks licensed in Hong Kong                                         40                        0


B. Liabilities and relevant amount pertaining to Hong Kong insurance business
                                                                 Items                                                          $
                            Unearned premiums                                                                   41
                            Additional amount for unexpired risks                                               42
                                                            Reported claims                                     43
                            Claims outstanding
  †Gross insurance                                          Claims incurred but not reported                    44
  liabilities (before
                            Fund                                                                                45
  deduction of amount
  reinsured)                Total liabilities (line 41+42+43+44+45)                                             46                        0
                            Deduct: Relief permitted under section 25A(8)                                       47
                            Total liabilities after deduction of line 47                                        48                        0
                            40% of line 48                                                                      49                        0
                            Unearned premiums                                                                   50                        0
                            Additional amount for unexpired risks                                               51                        0
                                                            Reported claims                                     52                        0
                            Claims outstanding
  Net insurance                                             Claims incurred but not reported                    53                        0
  liabilities (after
                            Fund                                                                                54                        0
  deduction of amount
  reinsured)                Total liabilities (line 50+51+52+53+54)                                             55                        0
                            Deduct : Relief permitted under section 25A(8)                                      56                        0
                            Total liabilities after deduction of line 56                                        57                        0
                            80% of line 57                                                                      58                        0
  The greater of line 49 or line 58                                                                             59                        0
  Relevant amount                                                                                               60                        0
  Total liabilities (line 59+60)                                                                                61                        0


* Supply particulars of assets in a separate sheet.
† Enter N/A in line 41 to line 49 if section 25A(3)(b) is not applicable.

NOTES :
Before submitting the Statement, please ensure :
(1) the Statement has been signed by 2 Directors and the Chief Executive/ Secretary of the insurer to certify the information contained
    therein is true and correct;
(2) supplementary information on the particulars of assets has been attached to the Statement; and
(3) the auditor's report (signed by the auditor) has been attached to the Returns.

				
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