Agency Application

Please complete all sections below.

1. Agent’s Details

Please complete all sections and options below.

Select an option (required)

2. Legal Status of the Agent

For partnerships and companies only, please list all partners / directors

Director 1
Director 2
Director 3
Director 4
Select an option (required)

3. Principal Place of Business Details

4. Registered Office Details

5. License Details

Select an option (required)
Select an option (required)
- Accounts & Records
- Insurance Administration
- Provision of Financial Services and Advice

6. General Insurance Activity

Which products do you wish this agreement to include?

Select an option (required)
Select an option (required)

State your estimated annual gross insurance premium income for:

7. Financial Position

Select an option (required)

8. Fitness & Propriety for Disclosure

Select an option (required)
Select an option (required)
Select an option (required)
Select an option (required)
Select an option (required)

9. Professional Indemnity Insurance

10. Client Money

Select an option (required)
Select an option (required)

DECLARATION

This declaration must be completed by the member applicant, as appropriate:

In the case of a sole trader – By the Sole Trader.
In the case of a company – By a Director.
In the case of a partnership – By a Partner.

I confirm that the information in this application is accurate and complete to the best of my knowledge and belief and that I have taken all reasonable steps to ensure that this is the case.

I give inet3 Ltd permission to contact the other Principals for whom I am an Appointed Representative.

I confirm that inet3 Ltd have permission to carry out credit checks - either on the individual if the applicant is a sole trader, on each partner in the case of a partnership or on the company in the case of a limited company. The credit check will be carried out in order to assess your application and on a repeat basis, usually annually.

Certify

Version 3 – April 2019