Agency Application Form
Please complete all sections below.
1. Agent’s Details
Please complete all sections and options below.
2. Legal Status of the Agent
For partnerships and companies only, please list all partners / directors
3. Principal Place of Business Details
Address of the principal place of business where the day-to-day business is transacted:
4. Registered Office Details
Address of Registered office (if different from head office above)
Please note the following categories required:
- Accounts & Records
- Insurance Administration
- Provision of Financial Services and Advice
6. General Insurance Activity
Which products do you wish this agreement to include?
If YES, please provide full details here separately
How do you usually source new Business?
State your estimated annual gross insurance premium income for:
10. Client Money
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.
Additional Information (optional):
Please tick this box to confirm that you have read, understood and accept the above declaration prior to submitting your application.
Version 3 – April 2019