APPLICATION FOR NEW BROKING AGREEMENT 1. FIRM DETAILS 1a. Full name of Broking Firm: 1b. Trading name of Broking Firm (if different from above): 1c. Registration number/masters ref. no.: FSP number: 1d. Please tick the applicable type of firm: Sole Proprietor Partnership Close Corporation Company Trust 1e. Year business established: Number of offices: Number of staff: Clerical Sales Total 1f. Is the Broking Firm a member of Life Underwriting Association of South Africa (LUASA), Insurance Brokers Council (IBC) or Black Brokers Forum (BBF), or has it been recognised by the Association for Savings and Investment South Africa (ASISA) as being a Participating Employer? If so, have all members of the firm who sell or will be selling Life Assurance been registered with ASISA? 1g. If 1(g) does not apply, do you understand that we are required to register with ASISA all members of the firm who sell or will be selling Life Assurance? NOTE: In terms of the Code on the Intermediary Register, no member office of ASISA or a participating employer may accept business from or pay commission to an intermediary who is not registered on the intermediary register with ASISA. Page 1 of 10 Participating employer is defined in the code as an employer that employs intermediaries or has a contractual relationship with intermediaries to sell long-term insurance products.
Bank stamp Old Mutual Application for new Broking Agreement Version 1.0 1h. Firm s postal address: Postal code: 1i. Firm s street address: Postal code: 1j. Dialling code + telephone number: Dialling code + fax number: Email address: 2. BANK DETAILS 2a. BANK DETAILS OF ACCOUNT INTO WHICH COMMISSION MUST BE PAID Name of accountholder: Name of bank: Account Number: Branch: Branch Code: Type of Account: Savings Current (cheque)* Transmission 2b. Bank details should be signed and stamped by an authorised official of the bank in the space below, thereby certifying that the information is true and correct. Date: Signature: * In the event of a current account, a cancelled or photocopied cheque may be attached instead. Page 2 of 10
3. VAT DETAILS If registered for value added tax (VAT), please insert your VAT registration number below. VAT number: 4. COMPLIANCE OFFICER S DETAILS Firm name (if applicable): Surname: Telephone number: First names: Fax number: Physical address: Principal s signature Date signed Page 3 of 10
PERSONAL PARTICULARS OF PRINCIPAL/AUTHORISED OFFICIAL 5. PERSONAL DETAILS 5a. Surname: First names: Preferred name: 5b. Identity (or passport) number: 5c. Date of birth: 5d. Gender: Male Female 5e. (i). Marital status: 5e. (ii). Type of marriage: (If married, 5e. (ii) is compulsory) 6. ADDRESS DETAILS 6a. Residential address: Postal code: 6b. Postal address (if different to residential): Postal code: 6c. Dialling code + telephone number: Cell number: Email address: Dialling code + fax number: Page 4 of 10
7. PREVIOUS EMPLOYMENT (PRINCIPAL) Please supply the following details in respect of your previous employment/s. Begin with the most recent. 7a. Sales Name of employer Job title Date work commenced Date work terminated Reason for termination Persistency if applicable 7b. Administrative Start date End date Nature of work performed Job title 8. FORMAL EDUCATION (PRINCIPAL) Please supply the following details in respect of your formal education: 8a. Secondary Education: Highest Grade/Standard passed: Year passed: Name of school at which you obtained the above Standard/Grade: 8b. Tertiary Education: Qualification Name of Institution Presently studying Yes/No Year qualification obtained 8c. Professional Education: Qualification Name of Institution Presently studying Yes/No Year qualification obtained Page 5 of 10
9. FIT AND PROPER REQUIREMENTS HONESTY AND INTEGRITY QUESTIONS PLEASE ANSWER THE FOLLOWING QUESTIONS: (Please tick the appropriate block) 9a. Have you ever been S coded? 9b. Have you ever entered into any form of composition with your creditors (Creditor s Agreement)? 9c. Has an adverse finding been made against you within a period of five years preceding the date of application in any civil or criminal proceedings by a court of law (whether in the Republic of South Africa or elsewhere) in which you were found to have acted fraudulently, dishonestly, unprofessionally, dishonourably or in breach of fiduciary duty? 9d. Have you within a period of five years preceding the date of application been found guilty by any professional or financial services industry body (whether in the Republic of South Africa or elsewhere), of an act of dishonesty, negligence, incompetence or mismanagement? 9e. Have you within a period of five years preceding the date of application been denied membership of any body referred to in paragraph 9d on account of an act of dishonesty, negligence, incompetence or mismanagement? 9f. Have you within a period of five years preceding the date of application been found guilty by any regulatory or supervisory body (whether in the Republic of South Africa or elsewhere) of an act of dishonesty, negligence, incompetence or mismanagement? 9g. Have you within a period of five years preceding the date of application been found guilty by any regulatory or supervisory body (whether in the Republic of South Africa or elsewhere), recognized by the Financial Services Board? Has an authorization to carry on business been refused, suspended or withdrawn by any such body on account of an act of dishonesty, negligence, incompetence or mismanagement? 9h. Have you at any time prior to the date of application been disqualified or prohibited by any court of law (whether in the Republic of South Africa or elsewhere) from taking part in the management of any company or other statutorily created, recognized or regulated body, irrespective whether such disqualification has since been lifted or not? 9i. Have you been refused the right to carry on or restricted from carrying on a trade, business or profession for which a specific licence, registration or other authority is required by law in any country? 9j. Have you been issued with a prohibition order under any law administered by the Financial Services Board or been prohibited by other regulatory bodies from operating in the financial services industry? 9k. Have you been involved with a corporation, which has been censured, disciplined, suspended or refused membership or registration by a stock exchange, futures exchange, other market or regulatory authority? 9l. Have you had any judgment (including a finding of fraud, misrepresentation or dishonesty) given against you in any civil proceedings, in South Africa or elsewhere or are there any proceedings now pending which may lead to such a judgment? 9m. Have you knowingly or negligently aided or abetted other persons in the breach of any laws, regulations, exchange rules and/or codes of conduct? Page 6 of 10 YES NO
9n. Have you been the subject of any investigation or disciplinary proceedings by any regulatory authority (whether in the Republic of South Africa or elsewhere) or exchange, professional body or government body or agency? 9o. Has your estate ever been sequestrated? If yes, have you been rehabilitated? 9p. Have you ever been a controlling shareholder, director of a company or member of a close corporation at the time it was placed under judicial management or in provisional or final liquidation? 9q. Are proceedings pending for the sequestration/liquidation of the firm, or for the firm to be placed under judicial management? 9r. Have you ever been refused a licence or registration in any place under any law which requires licensing or registration in relation to securities, futures, leveraged foreign exchange or insurance activities? 9s. Have you ever been refused authorisation to carry on business by any regulatory body (whether in the Republic of South Africa or elsewhere), recognised by the Financial Services Board, or has such authorisation ever been suspended or revoked by any such body, because of negligence, incompetence or mismanagement? 9t. Do you have any additional information, which should be brought to our attention, which may have an impact on our evaluation of your good character and integrity? YES NO 9u. If any of these questions have been answered yes, please provide an explanation below. 9v. Has any Life Office declined to grant, or cancelled a Broking Agreement with the firm, declined to grant, or cancelled an arrangement for annualized commission? If so, supply details. 9w. Has the firm, any principal or any salesperson employed by the firm, been employed by a moneylender, or carried on a business involved in money-lending or financing transactions? If yes, please give details. Please also state whether loans were agreed to subject to the borrower effecting a life assurance policy. Page 7 of 10
CURRENT OPERATIONS 10. MARKETS 10a. Please indicate where you currently market life assurance products: Private Sector Public Sector of total business of total business Average premium of existing client base R pm 10b. Private Sector business (if applicable): Are your clients generally worksite-based (i.e. confined to a particular workplace)? Yes No split of payment method: Debit Order Stop Order What is the average salary range of your existing clients? < R1 000 R1 001 R3 000 R3 000 R6 000 R6 001 R9 000 > R9 0001 Are any of your clients employees of national businesses/retail operations? Yes No 10c. Public Sector business (if applicable): Which employment sectors do you currently market life assurance to? Teachers Nurses Police Correctional Services Defence Force Other: Are your clients generally worksite-based (i.e. confined to a particular workplace)? Yes No split of payment method: Debit Order Stop Order Page 8 of 10
10d. Existing Life contracts held Average monthly production Contract Basis Company Contract % of Total Monthly Annual Sanlam Metropolitan African Life Capital Alliance Regent Other (state) Total 100% 10e. Nature of total business: Type: : Life Investment Personal Insurance (Short-term) Group (Compulsory) Assurance Collective Investments Other (state) Total 100% Page 9 of 10
11. DECLARATION 11.1 ACCEPTANCE OF BROKING AGREEMENT I acknowledge that the firm has no authority to obtain any new business for Old Mutual until an official Broking Agreement has been issued to and accepted by it, by duly signing and returning the signed Broking Agreement to Old Mutual. Any payments of commission and/or remuneration in respect of any business that may be introduced by the firm prior thereto will be at the entire discretion of Old Mutual, whose decision shall be final and binding on the firm. 11.2 NOTIFICATION OF CHANGES Should a Broking Agreement be granted to the firm, I undertake to supply Old Mutual with full details when a sales person is appointed or terminates his/her services with the firm. I also undertake to advise Old Mutual immediately, in writing, of any change in Directors/Partners/Owners/Trustees, a change of banking details or change of address. I will comply with all the rules and conditions laid down by Old Mutual. I further agree that this application will form part of my Broking Agreement with Old Mutual. 11.3 SHARING OF INFORMATION I accept that I am curtailing the firm s right to privacy, but to facilitate the assessment of this or any other application for a Broking Agreement, I irrevocably authorise Old Mutual to obtain from any person or institution, whom I hereby so authorise and request, to give any information which Old Mutual deems necessary and to share with others that information and any information contained in this application or in the Intermediary Register either directly or through the database operated by or for insurers as a group. 11.4 VAT DETAILS I undertake not to issue Old Mutual with any tax invoices, debit notes or credit notes in respect of any of the transactions on which VAT is payable. I task Old Mutual to annually supply me with an IT3(a) certificate that reflects the VAT component of commissions earned. 11.5 FIT AND PROPER HONESTY AND INTEGRITY I authorise Old Mutual to make any enquiries it may deem necessary from any institution or person and I authorise such office or person to give Old Mutual full and complete replies to its enquiries. I also acknowledge that, should any of the information given by me be false or incomplete, and this is subsequently discovered by Old Mutual, the Broking Agreement may be terminated immediately and I may be debarred with the Financial Services Board. I hereby declare that the above is true and correct. NAME: CAPACITY: SIGNATURE: DATE: Page 10 of 10