Bonus Underwriter

Commercial Insurance Introducer Agency - Application Form

If you have an existing agency with Select & Protect, advice your agency reference

Name of applicant:
Title
First name:
Surname:
   
Company name:
Address:
Trading name:(if different)
   
Contact name (if different):
Title:
First name:
Surname:
   
Contact details:
Telephone Office:
Mobile:
Fax:
E-mail:
Website address
Registered address
   
Legal status Regulatory status
Sole trader
Limited Liability
Partnership
Private limited company
Public limited company
Other
1. Authorised by the FSA for arranging (bringing about) deals in investments for:
Non-investment insurance business
Other areas of business
FSA Firm reference number

2. AR and/or IAR of others:
Your FSA form reference number
Does your principal(s) prohibit you from introducing business to us? YES NO
3. Neither FSA Authorised or an AR/IAR
Identification

For a private individual, we will require copies of identification documentation - one from column A and two from column B below. For companies, we will require a copy of one identification document from column A

If originals are sent they will be returned to you by Special Delivery post. Photocopies are acceptable and will be security shredded by us unless you specifically request they are returned to you.
Sole Trader

A

Passport

Current UK or EEA Driving Licence

Birth Certificate

Inland Revenue Tax notification, in respect of, or dated during the current or last year

Companies House registration

VAT registration document

PII Insurance documentation


Company Companies House registration

VAT registration document

PII Insurance documentation

B

Public utility bill or book i.e. gas, electric, water, phone (land line), issued or dated within the last three months

Local Authority bill (council tax bill) valid for the current year

Bank, Building Society or credit card statement issued within the last three months

Mortgage statement or tenancy agreement

NHS Medical Card