Assurant Solutions
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Application Form

Application to operate an Assurant Intermediary Agency

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