Agency

Full legal entity name *

Additional trading name(s)

Company registration number *

Date company established *

Business address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Contact Number *

Email *

Number of staff employed in the business *

Give details of any holding, subsidiary or associated companies (including appointed representatives)

have disciplinary details:

Will any associated companies require access to the care scheme? *

Please give details of the associated companies that require access *

How much GWP do you have relating to products for the care sector? (£) *

Gross written premium, in pounds.

GWP split: Residential Care (%)

GWP split: Supported Living (%)

GWP split: Domiciliary Care (%)

GWP split: Other (%)

Who are your top 3 providers for care at present? *

Banking details

Are you a member of a Network for insurance broking? *

Name of Network *

Do you hold client money (and have regulatory permission to do so)? *

Please provide an email address for Accounts queries (such as statements) *

FCA reference number *

These details relate only to the applicant. Do not include details of any holding, subsidiary or associated companies.

Give details of any professional bodies to which you belong

Disclosures

Has the applicant or any Director, Partner or Principal of the applicant:

Had any agency or similar agreement with any insurer refused or cancelled or had credit terms withdrawn? *

Been subject to disciplinary proceedings instituted by any professional or regulatory body? *

Been convicted of any criminal offence other than a minor motoring offence? *

Been subject to a County Court judgement or order? *

Been adjudged bankrupt, subject to a receiving order, entered into an arrangement with creditors or been involved with any business which has gone into liquidation, or is any such matter pending? *

Any other business interests not disclosed in this application? *

You answered Yes to one or more of the questions above. Please give details: *

Do you hold Professional Indemnity Insurance? *

In the last five years, have there been any incidents resulting in a claim against you for negligence, errors or omissions involving Professional Indemnity Insurers or otherwise? *

Please give details *

Declaration *

I am authorised to sign on behalf of the applicant and I/we agree to the declaration above

I/We hereby apply for agency facilities with Aldium Insurance Services Ltd trading as Accuro Underwriting and:

Confirm that to the best of my/our knowledge and belief the information supplied is true and correct and nothing has been withheld which might influence this application
Agree to accept and abide by the Terms of Business Agreement which forms the basis of this agreement
Agree to advise Accuro Underwriting of any material changes to the information supplied in this agreement

Authorised signatory (for and on behalf of the applicant) *

First

Last

Typing your name here acts as your signature.

Designation *

Date *

Apply for an agency

Agency application form

Banking details

Disclosures