A. Statement to be signed by the policy-holder under Article 13(1), second indent
"I hereby state that I wish (name of intermediary) to provide me with information on assurance contracts offered by undertakings established in Member States other than (Member State of habitual residence of policy-holder). I understand that such undertakings are subject to the supervisory arrangements of the State in which they are established and not to the supervisory arrangements of (Member State of habitual residence of policy-holder).'
B. Statement to be signed by the policy-holder under Article 13(2)
"I hereby take note that (name of assurer) is established in (Member State of establishment of assurer) and I realize that supervision of that assurer is the responsibility of the supervisory authorities in (Member State of establishment of assurer) and not the responsibility of the authorities in (Member State of habitual residence of policy-holder).'