Introducer Agency Application Form

Application to operate an Assurant Intermediary Introducer 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)


Postcode
Do you have an agency with Assurant?		Yes	No
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

BANK DETAILS
Account name		Account No
Bank name		Sort Code
Address


		Postcode

Please answer the following questions:
1.	Are you authorised by the FSA to sell GI?			Yes No
2.	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
3.	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
	B/ Been subjected to disciplinary proceedings by a regulatory or professional body?			Yes No
	C/ Been involved with any business that has gone into receivership or liquidation?			Yes No
4.	Have you ever been authorised by the FSA?			Yes No
5.	Have you ever been subject to, or is currently subject to enforcement action by the FSA?			Yes No
6.	Are you or have you ever been the subject of an investigation into allegations of misconduct or malpractice in connection with any business activity?			Yes No
7.	Have you ever been subject to bankruptcy proceedings?			Yes No
8.	Are you currently solvent?			Yes No
9.	Do you have any current judgement debts (including CCJs) made under a court order still outstanding either in full or in part?			Yes No
10.	Have you ever been convicted of, or been the subject of any criminal convictions, whether or not in the United Kingdom?			Yes No
11.	Are you the subject of any criminal proceedings?			Yes No
12.	Are there any other factors relating to you that could pose any risk to Assurant intermediary? The business must notify compliance of any factors regarding the agent that it is unsure about.			Yes No
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