Application Form

Application to operate an Assurant Intermediary Agency (* = required field)

Company name *
 		 Tel. No *
 
Address
 		 Fax No
 
 
 		 Email *
 
 
 		 Mobile No
 
 
 		  Reference  
Postcode
 		    
 
Nature of business
 		 Sole trader  (Please tick as applicable)
  Partnership  
Date established
 		 Limited Co  
Company Registration No
 		 LLP  
Registered Address
 		 Other  
(if different from above)
 		 Number of Advisers
 
 
 		    
 
 		    
Postcode
 

    
Please enter full contact names and titles e.g., Director, partner, Proprietor etc.
Name
 		 Job Title
 
 
Name
 		 Job Title
 
 
Name
 		 Job Title
 
 
Name
 		 Job Title
 
 
Compliance Officer
 

 Tel. No
 
GENERAL INSURANCE INFORMATION
Professional Memberships
CCL No
 		 Date issued
 		    
FSA No
 		 Date issued
 		    
Network Principal
 		 Date Effective
 		    
Mortgage Club
 		        
Professional Indemnity Insurance
Insurer's name
 		 Amount of cover
 		 Last Renewal date
 
BANK DETAILS
Account name
 		 Account No
 
Bank name
 		 Sort Code
 
Address
 		    
 
 		    
 
 		    
 
 		 Postcode
 
 
Please answer the following questions:
1. Have you, as an individual, director or partner ever had your registration or enrolment of any professional or statutory body denied or terminated? Yes  No If 'Yes', please give details below
2. Have you, as an individual, director or partner, or has a fellow director or partner ever:
(a) had a similar agency with any insurer/provider denied/terminated? Yes  No If 'Yes', please give details below
(b) been subject to disciplininary proceedings by a regulatory or professional body? Yes  No If 'Yes', please give details below
(c) been involved with any business that has gone into receivership or liquidation?

 Yes  No If 'Yes', please give details below
DECLARATION
I/We apply for an agency with Assurant Intermediary Ltd and confirm that to the best of my/our knowledge and belief, the information given in this application is true and accurate. I/We agree to notify of any changes in information/circumstances within the organisation. I/We will ensure that all employees, consultants etc., will receive full training by the relevant regulatory body, including full product knowledge.
ADDITIONAL INFORMATION