Broker Agency Application

Agency Details

Select the areas of Insurance you are interested in

Travel

Personal Accident

Financial Professions

Excess Liabilities

Commercial

Agency Name in full:

Trading Name (if different from above):

Registered Address (if different from above):

Number of Branches:

Telephone Number:

Website Address:

Daily Contact Name:

Job Title:

Daily Contact Email:

Professional Indemnity Insurer:

Policy Number:

Inception Date:

Renewal Date:

Limit of Indemnity:

Excess:

Compliance Contact Name:

Compliance Email Address:

Are you fully authorised with the FCA for insurance sales:

If No, please continue to complete this application, however we will need to contact you with regards to further verification details.

Yes

FCA Authorisation No:

Are you an Appointed Representative of an authorised firm?

Yes

Who is the Principal firm?

What is their FCA FRN?

This is where monthly broker account statements will be issued to for settlement

Accounts Contact Name:

This is where monthly broker account statements will be issued to for settlement

Accounts Email Address:

Accounts Telephone Number:

Are you a member of any Broker Network?

If yes, then please provide details.

Yes

Which software platform(s) do you use? E.g. Acturis

Where did you hear about DOA?

Please enter any additional information here:

Do you verify your clients' identity?

Yes

Please provide extra details

Do you check clients against appropriate sanctions lists?

Yes

Please provide extra details

Do you undertake checks to comply with money laundering regulations?

Yes

Please provide extra details

Do you have anti-bribery and corruption procedures in place?

Yes

Please provide extra details

Do you have data protection procedures in place?

Yes

Please provide extra details

Do you have a treating customers fairly procedure in place?

Yes

Please provide extra details

Do you perform credit checks on your clients?

Yes

Please provide extra details

Declarations

We confirm that: To the best of our knowledge and belief the information contained in this application is correct and that we have taken all reasonable steps to ensure that this is the case?

Yes

Please provide extra details

The Firm holds all necessary licenses in all appropriate jurisdictions and classes to conduct insurance business and to enable it to send insurance business to DOA?

Yes

Please provide extra details

We have in place policies and practices that promote compliance will all applicable laws, rules, regulations and standards relating to anti-bribery and anti-corruption law in any relevant jurisdiction, including the UK?

Yes

Please provide extra details

None of our employees, officers, directors or shareholders has ever been convicted of any offence involving fraud, bribery, theft, false accounting or other dishonesty, or is the subject of any current criminal/civil proceedings or regulatory investigations/disciplinary actions?

Yes

Please provide extra details

No previous application by our firm, directors or shareholders, for membership of any professional body ever been refused, cancelled, declined or withdrawn?

Yes

Please provide extra details

None of our directors or shareholders have ever been declared bankrupt or entered a composition with creditors?

Yes

Please provide extra details

The Firm will advise DOA in writing of any subsequent material change to the above information?

Yes

Please provide extra details

I confirm I have authority to sign on behalf of the Firm

Yes

Please provide extra details

Please CLICK HERE to read the Terms of Business Agreement (TOBA).
Please ensure you print off a copy of this TOBA for your records as this will form the basis of your agency agreement with us.

I confirm that I have read and accepted the TOBA