COVERSURE Insurance Services. Franchise Application FORM. coversurefranchise.co.uk

Transcription

1 COVERSURE Insurance Services Franchise Application FORM coversurefranchise.co.uk

2 Franchise Application Form Please fill in this form online and print off the completed copy to sign and date. 1. Personal details Title: Mr Mrs Miss Other: Surname: First Name(s): Home telephone number: Mobile number: Date of birth: Number of dependants: Marital status: Name of spouse/partner: Time at current address: Please supply previous address(es) if your time at your present address is less than 3 years From: To: From: To: 2. Your home Living status: Homeowner Tenant Living with parents Other: Monthly payment on mortgage / rent: If you have a mortgage, mortgage balance outstanding: Term of mortgage remaining:

3 3. Your current employment Employer / name of your business: Business Time with present employer: 4. Your employment history:

4 5. Your bank details Name of bank: Branch Sort code: Account number: Time with bank: 6. Your financial details Gross annual income: Total household income (e.g. spouse s or partner s income): Other sources of household income: Details of outstanding financial commitments (e.g. loans, hire purchase commitments). Please provide details of all that apply. Continue on section 14 if required.

5 7. Professional details Solicitor s name: Telephone number: 8. Your referees Name: Occupation: How known: Name: Occupation: How known: Name: Occupation: How known: 9. Professional and compliance Please list your professional qualifications: Have you previously been approved by the FCA? Yes No Are you currently an approved person? Yes No Are you currently acting as a controller as defined by the FCA? Yes No

6 10. Other business interests Do you have any other business interests? Yes No If yes, please provide the following information Name of business: Type of business: If limited company, company registration number: Your position (e.g. principal, partner, director): 11. Existing brokers only - if not applicable please go to q12 If you currently run an existing broking business, please provide the following information Name of business: Post code: When established: If limited company, company registration number: FCA status (e.g. independently authorised, appointed representative): FCA registration number: Details of any past or current disciplinary action against you/your firm by the FCA: Have you ever had any agencies with insurers cancelled (other than due to lack of support): Yes If yes, please advise name of insurer(s), date of cancellation and reason for cancellation: No 12. Your motivation - Please summarise why you wish to apply for a coversure Franchise Please state your reasons for wanting a Coversure franchise and why you feel you would be successful: 13 Proposed location of office (IF REQUIRED) Office type (e.g. shop front, serviced office):

7 14. Other relevant information Please add any additional information that may help us to assess your application: We will also require copies of the following documents: (Please indicate you have included these) Latest trading accounts (if you have had a business in your own name). A full CV A letter addressed to your bank giving your permission to release a reference to us 15. Declaration In connection with this application, Coversure Insurance Services Ltd will use the information supplied on this form, together with any information subsequently supplied by you, to carry out initial and subsequent regular credit checks with credit reference agencies which will retain a record of those searches. I hereby declare that I have never been bankrupt or been a director of a company that has been liquidated. I further declare that I have never been convicted of any criminal offence nor had any CCJ awarded against me. I hereby warrant that all information I have given is true and accurate and that any false or inaccurate information provided may invalidate my application and, if granted, may result in termination of my franchise with Coversure Insurance Services Ltd. Signed: Date: Print Name: