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Company Registration

Company Information

Do you hold any relevant memberships/subscriptions?


Do you provide any specialist schemes within the Insurance Market?

Yes No

Do you place business provided by or on behalf of any sub agents/sub brokers/introducing brokers?

Yes No

Please note the application is subject to the Company, Director and/or owner of the applying brokerage having not been:

  • charged with or convicted of any criminal offence other than a minor motoring offence in the last 12 months.
  • subject to a claim under your professional indemnity insurance policy in the last 10 years.
  • a party to any legal proceedings or action, nor has any such actions pending in which you or the Company have been named as a defendant in the last 12 months.
  • subject to liquidation, receivership, bankruptcy or administrative order.
  • entered into or proposes to enter into an agreement or assigned with creditors or otherwise acknowledged insolvency.
  • disqualified under Company Law.
  • criticised, fined, disciplined, suspended or expelled by any insurance industry trade association or regulatory body.
  • refused, suspended, withdrawn or not renewed a licence or authorisation to conduct insurance business.
  • asked to resign excluding redundancy or been dismissed from any previous office or employment.
  • or currently act as a Directors of any other financial services sector organisation or organisation that may provide services under this agreement?

I can confirm the above is true and correct*

Any other information which may be relevant to this application?