The Applicant
Trading Name:
(if not a limited company, please state whether a partnership, sole trader or other)
Name and title of person responsible for agency:
Head/Registered office address inc postcode:
Address Line 1
Address Line 2
Address Line 3
Address Line 4
Postcode
Contact information:
Office
Direct (if applicable)
Fax
Email
Website
Co. Reg. No
Please describe these premises :
(e.g first floor office, ground floor shop, private house)
Name and title of person responsible for Accounts :
Accounts correspondence address inc postcode: (if different from above)
Address Line 1
Address Line 2
Address Line 3
Address Line 4
Postcode
Accounts contact information:
Office
Direct (if applicable)
Fax
Email
The Firm
Number of Branches
if more than one branch, please complete the fields below if neccessary:
Branch No
Address Including Postcode
Main Contact
Telephone
1
2
3
4
5
Please state the firm's FSA Firm Reference Number:
Is the firm a member of the following bodies:
BIBA:
Yes:
No:
IIB:
Yes:
No:
Please give details of your Professional Indemnity insurance:
Limit of indemnity £
Insurer
Expiry date
Excess £
Associated Businesses
Is your business associated with or controlled by:
any other insurance industry business?
Yes:
No:
any business not connected with the insurance industry?
Yes:
No:
Have you ever traded under a different name?
Yes:
No:
If yes to any of the above, please give full details and other material information:
Directors & Principals
Name
Age
No. Years Experience
Where experience obtained. Qualifications, experience & affiliations, if any:
Has the business or any of the persons named above
had an insurance agency or membership of a trade association or statutory body refused, suspended, cancelled or withdrawn?
Yes:
No:
had a county court judgement against them, received a police caution, been convicted of or charged with but not yet tried for any offence other than driving?
Yes:
No:
or any business in which they have been involved become bankrupt, insolvent, appointed receivers, called a meeting of creditors or entered into compulsory or voluntary liquidation?
Yes:
No:
If yes to any of the questions, please give full details
Financial Information
Please provide the following names and addresses:
Your Bank
Bank Name
Address Line 1
Address Line 2
Address Line 3
Postcode
Your Accountants
Your Accountants
Address Line 1
Address Line 2
Address Line 3
Postcode
What is your estimated premium income for the next twelve months? (£)
What proportion of your premium income relates to the following classes?
Household %
Commercial including fleet %
Private motor %
Other %
How many agencies do you operate?
Please list the major agencies, indicating whether you have ‘Club’ status with any of them:
Name
Club Status
Do you operate any niche schemes?
Yes:
No:
If Yes, please indicate what they are:
Expected number of quote requests to be referred/submitted to Plum Underwriting over next year?
Expected GPI of applicable business to be referred to Plum Underwriting over next year?
Information required for online quotation facility set-up - “The Broker Centre”
Username and Password
Your username and password will be confirmed to you by email once your agency has been approved. The username can be shared by all members of staff.
If you have more than one branch, we will issue one username per branch.
Where did you hear about Plum Underwriting?
Who referred you to obtain an agency from Plum Underwriting? (if applicable) :
- Please Select -
Bluefin BPS
COBRA Network
Marsh Labyrinth
Marsh Connections
Marsh ProBroker
Park Consultancy
Blink
No One
*Other
*If Other please fill in the following :
Information
Any additional information:
Declaration
I/we declare that all the information given in this application form is, to the best of my/our knowledge, true and complete.
I/we agree that the completed form and any additional information I/we provide will be the basis of the agreement between me/us and
Plum Underwriting Ltd should it be granted.
I confirm that I am authorised to complete and submit this Agency Application form on behalf of my company.
Full name
Postion Held
Date
