Agency Application Form Apple Underwriting

Transcription

1 Agency Application Form Apple Underwriting Apple Underwriting 2 6 Bridge Street, Shotton, Deeside, Flintshire. CH5 1TW. Scott.Woodward@AppleUnderwriting.co.uk Tel : Or Tasha.Williams@DeesideInsurance.co.uk Tel : This Agency Application Form, is to be completed by all intermediaries requiring direct dealing facilities. Please . Page 1 of 12

2 Full Name of Company All Trading Names of Company Full Postal Address & Postcode & Registered Office if different. Telephone Number Address Address for Accounts Person / Team Website Date Company Established Type of Company (Ltd, Plc, Sole Trader, etc) Page 2 of 12

3 Company Registration Number FCA Firm Reference Number Date authorised Name and details of ALL Directors / Partners / Silent Partners / Shareholders / Non Executive Directors / Principals : Name Address & Postcode Age Experience / Qualifications Page 3 of 12

4 Question - Please tick box. Yes No Has any Director, Partner or Executive EVER been declared bankrupt or been compounded by creditors? Has any Director, Partner or Executive EVER had a County Court Summons issued against them? or County Court Judgement issued against them? Is the Company associated with any other Firm of Insurance Brokers, Intermediaries or Financial Advisors? Is the Company Associated with, Owned or Controlled by any other Company not connected with the insurance industry? Has any Insurance Company, Lloyds Broker or Syndicate EVER cancelled or refused you an agency? If, you have answered YES, to any of the above, please provide details on additional information sheet. When is your Financial Year End? What was your Turnover last Financial Year? What is your estimated Turnover for current financial year? Number of Full Time staff? Number of Part Time Staff Type of business premises occupied (e.g. ground floor, shop / offices, private house, first floor suite, call centre, etc) Page 4 of 12

5 Name of Bankers Bank Manager Address of Bankers Postcode of Bankers I consent to you providing a written bank reference to Apple Underwriting Signed Name on behalf of Date Do you require two signatories on all outgoing payments? If, Yes, please supply names of signatories. Name of Accountants Address of Accountants Postcode of Accountants Page 5 of 12

6 Details if you are a Registered member of any Governing Body or Trade Association or Professional Body? Which bodies are you Regulated by. Details if you are part of any broker network? Regulation : Do you hold client money in a separate client account? Yes or No If YES, please confirm type of Bank Account used? Tick box Non Statutory Trust Bank Account Statutory Trust Bank Account If No, please confirm type of Bank Account used? Tick box Company Trust BIBA Trust Page 6 of 12

7 Do you have permission to conduct consumer credit activities? Yes or No Are you registered under the Data Protection Act? Yes or No If Yes, please confirm your registration number Are you authorised by the Ministry of Justice in relation to claims handling under the Compensation Act 2006? Yes or No Pleas list the classes of business the Company places? Page 7 of 12

8 Please confirm your 5 largest Accounts with whom you place business? Name of Insurer Annual GWP 1) 2) 3) 4) 5) Do you obtain business via Aggregators? If Yes, which aggregators are you on? Lloyd s Brokers / Lloyd s Syndicates : Do you have existing or previously used Lloyd s Broker s and / or Lloyd s Syndicates? If so, please provide names. Page 8 of 12

9 To help us advise offer / market appropriate products : Please provide the annual GWP : Products Annual GWP Number of Clients Contents only policy Buildings only policy Building and Contents policy Family Legal Cover Home Emergency Key Care Breakdown cover for vehicles Other please specify - example Commercial Do you use Appointed Representatives? If so, please provide full details. Page 9 of 12

10 Business Profile Details Personal Lines Split Commercial Lines Split Geographical spread of customers Major Product Lines are Computer Systems : Details Which Computer systems / software houses do you use? Do you have access to England, Scotland and Wales Home Writer? Do you have access to Northern Ireland Home Writer? Can you print off laser proposal forms, schedules, certificates, etc? Page 10 of 12

11 Do you have written Systems and Controls and Company Procedures for : Yes No Treating Customers Fairly? Data Protection Act? Disaster Recovery Plan? IT security Policy? Bribery Act? Conflict of Interest Policy? Sanction Checking? I / We warrant that the information given by me / us is true, complete and accurate is all respects. I / We undertake to advise immediately of any alterations to the information disclosed in this application form. I / We authorise Apple Underwriters (Deeside Insurance Brokers Ltd), to make enquiries that are deemed necessary in connection with this application form and obtain references where necessary. I / We declare that all the individuals named in this application form, authorise Apple Underwriters (Deeside Insurance Brokers Ltd), to receive, hold and use the information contained herein, under the provisions of the Data Protection Acts 1984 and I / We agree that Apple Underwriting may disclose information from this application in order to secure insurance facilities on my behalf. Page 11 of 12

12 This application form has been completed by : Signed Full Name Date Position in the Company Please attach the following documents, along with a completed agency application form. Documents to attached Last financial year set of Accounts including the Auditors report Copy of your latest Professional Indemnity Insurance Certificate Checklist Yes / No Yes / No Staff Training Policy Yes / No Apple Underwriting is a trading name of Deeside Insurance Brokers Ltd. Est Page 12 of 12