Insurance Agency Application Form

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The purpose of this form is to fulfill our regulatory obligations by performing a process of vetting and approval of your business before we enter into a contractual relationship with you. We wish to work only with those who are committed to our standards and we will undertake due diligence to ensure this.

Throughout our operations we maintain systems and controls for compliance with applicable requirements and standards under regulatory guidance as set out by the Financial Conduct Authority. Importantly, this includes policies and procedures for countering the risk of becoming involved in financial crime. We maintain a policy of zero tolerance towards bribery and corruption in all forms, whether directly or through third parties.

Please confirm the following:*

I/We hereby make an application to become an agent of Inksurance.

I/We enclose a copy of our most current Professional Indemnity Insurance certificate.

I/We attach a copy of our Group structure chart showing our ultimate parent company together with any subsidiary and affiliated companies.

I/We attach a copy of our most recent Report and Accounts and Group Report and Accounts where relevant.

Company Details

Company Name*

Trading Name (if applicable)

Country of Registration & Company Registration Number (if applicable)

Date Established

Organisation Type /Legal Status (please tick one)

Sole Trader

Private Limited Company

Unincorporated Association

Partnership

Public Limited Company

Limited Liability Partnership

Other

Trading Address

Street Address City ZIP / Postal Code

Trading Telephone Number

Registered Office

Street Address City ZIP / Postal Code

Registered Office Telephone Number

Website Address

Principal Business Activity

Primary Contact Name and Email Address*

Primary Contact Name at Inksurance

Please list below the name of Key Personnel, Principals, Directors, Partners or controllers in your business (a controller is a person who: (a) holds 20% or more of the shares or voting power in your firm, or in a parent of your firm; or (b) holds shares or voting power in your firm, or any parent, as a result of which the person is able to exercise significant influence over the management of your firm):

Person 1

Title/Forename/Surname

Date of Birth

DD slash MM slash YYYY

Address

Position Held

Time with the firm

Person 2

Title/Forename/Surname

Date of Birth

DD slash MM slash YYYY

Address

Position Held

Time with the firm

Person 3

Title/Forename/Surname

Date of Birth

DD slash MM slash YYYY

Address

Position Held

Time with the firm

Regulatory Information

Are you registered with the FCA? (if yes, please provide your FCA number; if no, please provide your regulatory authority you are registered with below together with the related registration number)

Yes

FCA Number:

Other Regulatory Authority:

If you are an appointed representative please state your Principals name and FCA number:

Are you author ised to hold client money? (if yes, please indicate below whether it is held in a statutory or non-statutory account)

Yes

Indicate whether it is held in a statutory or non-statutory account

Please confirm that any RMAR and Client Money obligat ions have been met

Yes

Please confirm that all Financial Sanctions and Anti-Bribery & Corruption checks are in place with any exceptions having been fully investigated

Yes

Additional Company Information

Are you registered under the Consumer Credit Act? (if yes, please provide details below including licence number)

Yes

Please provide details including licence number

Are you registered under the Data Protection Act? (if yes, please provide details below)

Yes

Please provide details

Do you have more than one branch that requires agency facilities (excluding any Appointed Representatives)? If YES please provide full address and contact details below

Yes

Please provide full address and contact details

What software system do you currently use?

Are you a member of a Network or Affinity Group? (if yes, please specify the name and your membership status)

Yes

Please specify the name and your membership status

Professional Indemnity

Do you currently hold professional indemnity insurance? (if yes, please attach a copy of your P.I. certificate)

Yes

PLEASE NOTE THE APPLICATION WILL NOT BE PROCESSED WITHOUT THIS INFORMATION

Please attach a copy of your P.I. certificate

Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.

Sales Information

Please provide details of the Gross Written Premium (GWP) for the types of general insurance that you currently provide:

What is your total Gross Written Premium? £

What is the Commercial split? £

What is the Personal split? £

Business Continuity Planning

Do you have a business continuity plan in place that meets FCA requirements? (if yes, please provide details below of when this was last tested or when it is due to be tested)

Yes

Please provide details of when this was last tested or when it is due to be tested

Inksurance Products

Please indicate below the reason as to why you would like to do business with Inksurance and those products that you wish to access:

Please indicate the level of GWP you anticipate providing Inksurance in your first year of trading with us: (£)

Bank Details

Business Account Details

Bank Name

Bank Address

Street Address City ZIP / Postal Code

Your Reference

Account Name

Account Number

Sort Code

SWIFT Code

IBAN

Client Money/Fiduciary Funds Account Details (if applicable)

Bank Name

Bank Address

Street Address City ZIP / Postal Code

Your Reference

Account Name

Account Number

Sort Code

SWIFT Code

IBAN

Inksurance Products

Has any Director, Partner, Proprietor or Manager personally or by association: If any of the below questions are answered as ‘Yes’, please provide further details in the bo x provided.

Been convicted of a crime involving dishonesty or breach of trust?

Yes