Intermediary Agency Application Form Intermediary details Give details of any group, parent company or broker network: Legal entity name: Trading names: Is the company an appointed representative? If yes, what is the name of the principal business? Registered office address: Trading business address: Main office telephone number: Main office email address: Director telephone number: Director email address: Accounts telephone number: Accounts email address: Company registration number: Date business established: Number of full-time staff: Number of part-time staff: Are you authorised by the FCA? Firm reference no (FRN): Are you registered under the Consumer Credit Act? CCL licence no: Branch offices (please attach a separate sheet if necessary) Tel no: Fax no: Tel no: Fax no: Email address: Email address: PolicyPlan Agency Application August 2017 - Page 1
Financial details Name and address of your accountants: Name and address of your bank: Financial year end: How do you hold client money? Risk transfer Statutory trust n-statutory trust Professional indemnity details Insurer: Indemnity limit: Expiry date: Current premium: Details of claims, including amounts: It is a condition of trading that adequate professional indemnity insurance be maintained at all times at the above level Directors/Partners/Principal (please attach a separate sheet if necessary) Have you or any director, partner, principal or member of staff ever: Been involved in liquidations, receiverships or bankruptcy? Received an administration order or entered into any administration agreement? Entered into any agreement with creditors that has been approved by the courts? Been found for negligence, fraud, misfeasance or wrongful trading? Been disqualified under company legislation? PolicyPlan Agency Application August 2017 - Page 2
Additional information Software provider (eg. Open GI, SSP, Acturis etc): Details of membership of computer/user/marketing groups: The name of your current guaranteeing broker: Compliance - please confirm whether you have the following policies in place Anti-Bribery and Corruption Financial Crime Vulnerable Customers Treating Customers Fairly Business continuity & disaster recovery Distribution details Will you ever use PolicyPlan products to transact business on behalf of affinity groups? If, please list all affinity group relationships: Will you ever use aggregators to quote for PolicyPlan products? If, please list all aggregator relationships: Please list all insurers with whom you currently hold agency facilities: PolicyPlan Agency Application August 2017 - Page 3
Business conducted Gross premium income: Last year Current year (forecast) Percentage split: Retail business Commercial business Premium income split: Van Private motor HGV Courier Motor trade Fleet Caravan Motorhome Public/private hire Motorcycle Commercial Specialist vehicle Household Liability Other (please specify) Travel Please provide two referees from the insurance industry (must be insurers) with whom you have conducted business within the last three years. By providing these details you are agreeing to PolicyPlan contacting them to obtain references. Contact name: Tel no: Contact name: Tel no: Claims management company Do you use any claims management (legal expenses/ulr) companies? If, please provide details Do you or any directors have any financial or controlling interest in any claims management companies? If, please provide details PolicyPlan Agency Application August 2017 - Page 4
Please provide any additional information you would like us to consider whilst we process your application: Personal data Application procedure This may involve PolicyPlan making further enquiries about the business and any individual within the business. Such enquiries may include: Credit searches on both the business and individuals References from the business accountant References from other financial services companies Searches of records held at Companies House Other records as deemed appropriate for the purpose of this application Please note that by signing this application you give PolicyPlan permission to request this further information. Data Protection Statement Under the Data Protection Act 1988 we have to tell you who is responsible for deciding how your personal information will be used. The information you provide on this form including any sensitive personal information (e.g. criminal convictions) will be used by PolicyPlan to assess your suitability for this application. This may include undertaking credit checks and seeking references for the purposes of verification, identification and in accordance with PolicyPlan s regulatory requirements to ensure you are fit and proper to perform the activities permitted under the agreement. We may share your relevant personal information with other companies to comply with our regulatory obligations and for ongoing administration, management information and marketing purposes. n-disclosure agreement We undertake not to use the information provided for any reason not detailed above. All information will be held in confidence and will not be made available to the market or placed in the public domain. Prior to returning this application, please ensure you have included all of the following: A copy of your professional indemnity insurance schedule A copy of your most recent reports and accounts Any other material information attached on a separate sheet Signature (must be CF1 Director): Print name: Date: PolicyPlan Agency Application August 2017 - Page 5