Intermediary Application – Unisure Solutions

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INTERMEDIARY PROFILE

Full registered name of Intermediary *

Trading name if different

Was the entity ever registered under a different name?

Please provide previous name(s)

Type of corporation (e.g. Limited Company, Sole Trader, etc) *

Date incorporated *

Registration Number *

Country of Incorporation *

Registered Address

Address Line 1 *

Address Line 2 *

City *

State/ Province / Region *

ZIP/ Postal *

Country *

Correspondence Address *

Correspondence Address is Same As Registered Address
Correspondence Address is Different

Correspondence Address

Address Line 1 *

Address Line 2 *

City *

State/ Province / Region *

ZIP/ Postal *

Country *

Intermediary Principal Contact 1

answered ZIP/ (and/or

Intermediary Principal Contact 1 *

First

Last

The main contact who will be responsible for completing this application and dealing with any queries relating to it.

Designation *

Email Address *

Phone Option 1 *

Phone Option 2

Do You Want to Add Another Principal Contact?

Intermediary Principal Contact 2

Intermediary Principal Contact 2 *

First

Last

Designation *

Email Address *

Phone Option 1 *

Phone Option 2

Are you a registered UNISURE LIMITED Intermediary?

Please fill in your reference number *

Unisure Solutions Representative Contact Name *

First

Last

Intermediary Administration Contact

Intermediary Administration Contact *

First

Last

Designation *

Email Address *

Phone Option 1 *

Phone Option 2

Company Telephone *

Company Website

Full name of each Director (or equivalent)

Director 1 *

First

Last

Director 2

First

Last

Director 3

First

Last

Director 4

First

Last

Director 5

First

Last

Are there more than five Directors?

Please list all additional Directors below

Full name of each Shareholder / Beneficial Owner representing at least 25% of voting equity (please ensure that each Ultimate Beneficial Owner is identified):

Shareholder / Beneficial Owner 1 *

Equity Share *

Shareholder / Beneficial Owner 2

Equity Share

Shareholder / Beneficial Owner 3

Equity Share

Shareholder / Beneficial Owner 4

Equity Share

Shareholder / Beneficial Owner 5

Equity Share

Are there more than five Shareholders?

Please list all additional Shareholders below, noting their respective Equity Share

SUPERVISORY AUTHORITY DETAILS

Name of Supervisory Authority *

Supervisory Licence Number *

Website of Supervisory Authority *

Number of years operating as an insurance / financial intermediary

Do you have passporting rights to distribute in other EU countries? *

Please provide the list of those EU countries

PROFESSIONAL INDEMNITY COVER

Please provide details of Professional Indemnity Cover *

Has the Intermediary (and/or its directors/partners/shareholders/guarantors/principal) ever been, or are they currently in the process of being dissolved, struck off, wound up or terminated? *

Has the Intermediary (and/or its directors/partners/shareholders/guarantors/principal) ever been, or are they currently party to any civil or criminal legal proceedings? *

Has the Intermediary (and/or its directors/partners/shareholders/guarantors/principal) ever had any regulatory authorisation, appointed representative status, terms of business or agency agreement refused, suspended or cancelled? *

Has the Intermediary (and/or its directors/partners/shareholders/guarantors/principal) ever been, or are they currently, the subject of disciplinary proceedings by any regulatory body, or professional association? *

Please provide more information if you have answered yes to any of the questions above

DOCUMENTS TO BE UPLOADED

Please attach the relevant statutory documentation that will assist us in doing the necessary due diligence on your company.

Documents Upload *

Click or drag files to this area to upload. You can upload up to 10 files.

Each upload has a maximum file size of 20 MB

Document Checklist - please tick as provided

Certificate of Incorporation
Certificate of Name Change (where applicable)
Register of Shareholders (which identifies the name of each shareholder / UBO)
Register of Directors
Group Companies Organisational Chart (if applicable)
List of Authorised Signatories
Evidence of Professional Indemnity Insurance
Company bank account details provided on letterhead*

*(Account name - Account number - Bank address - SWIFT / BIC - IBAN).

Thank you for entering your reference code, after clicking submit below a representative will confirm your code and will be in contact with you.

DECLARATION

Please tick to confirm *

We confirm that persons completing this application are properly authorised to do so on behalf of the Intermediary. We agree that we will provide any information reasonably requested by Unisure Solutions, which may assist in evaluating this application.

Please tick to confirm *

We confirm that all answers given are true and correct.

Please tick to confirm *

We confirm that we will notify Unisure Solutions immediately if there are any changes to the directors, shareholders, ultimate beneficial owners, or controllers of the entity; or the legal status, regulatory status or domicile of the entity.

Please tick to confirm *

We authorise Unisure Solutions to conduct reasonable status enquiry searches about us.

Please tick to confirm *

We confirm that we have systems and controls in place to ensure that appropriate Know Your Customer procedures are followed for all prospective customers prior to the submission of a proposal.

Please tick to confirm *

We agree that information provided by us in connection with this application will become part of the data held by Unisure Solutions. We understand that the information supplied, including personal data, will be used by Unisure Solutions for the purpose of establishing terms of business and for continuing administration.

Please tick to confirm *

We hereby give consent that information and data may be shared with authorised sub-processors in line with the Privacy policy.

Name of person responsible *

First

Last

The representative within the organisation with overall internal responsibility for ensuring compliance with its Data Protection obligations.

Position *

Date *

EU Intermediary Application

INTERMEDIARY PROFILE

Registered Address

Correspondence Address

Intermediary Principal Contact 1

Intermediary Principal Contact 2

Intermediary Administration Contact

Full name of each Director (or equivalent)

Full name of each Shareholder / Beneficial Owner representing at least 25% of voting equity (please ensure that each Ultimate Beneficial Owner is identified):

SUPERVISORY AUTHORITY DETAILS

PROFESSIONAL INDEMNITY COVER

DOCUMENTS TO BE UPLOADED

Thank you for entering your reference code, after clicking submit below a representative will confirm your code and will be in contact with you.

DECLARATION

Information

Information

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