Security-Insured-Agency-Application-Form

Producing Broker Application Form

The purpose of this form is to fulfill our regulatory obligations by performing a process of vetting and approval of your business before we enter into a contractual relationship with you. We wish to work only with those who are committed to our standards and we will undertake due diligence to ensure this.

Throughout our operations we maintain systems and controls for compliance with applicable requirements and standards under regulatory guidance as set out by the Financial Conduct Authority. Importantly, this includes policies and procedures for countering the risk of becoming involved in financial crime. We maintain a policy of zero tolerance towards bribery and corruption in all forms, whether directly or through third parties.
Please confirm the following:*
- Select All
- I/We hereby make an application to become an agent of Security Insured.
- I/We enclose a copy of our most current Professional Indemnity Insurance certificate.
- I/We attach a copy of our Group structure chart showing our ultimate parent company together with any subsidiary and affiliated companies.
- I/We attach a copy of our most recent Report and Accounts and Group Report and Accounts where relevant.

Please list below the name of Key Personnel, Principals, Directors, Partners or controllers in your business (a controller is a person who: (a) holds 20% or more of the shares or voting power in your firm, or in a parent of your firm; or (b) holds shares or voting power in your firm, or any parent, as a result of which the person is able to exercise significant influence over the management of your firm):
Person 1
Title/Forename/Surname
Date of Birth
Date Format: DD slash MM slash YYYY
Address
Position Held
Time with the firm
Person 2
Title/Forename/Surname
Date of Birth
Date Format: DD slash MM slash YYYY
Address
Position Held
Time with the firm
Person 3
Title/Forename/Surname
Date of Birth
Date Format: DD slash MM slash YYYY
Address
Position Held
Time with the firm

Security Insured Products
Please indicate below the reason as to why you would like to do business with Security Insured and those products that you wish to access:
Please indicate the level of GWP you anticipate providing Security Insured in your first year of trading with us: (£)
Bank Details
Business Account Details
Bank Name
Bank Address
Street Address City ZIP / Postal Code
Your Reference
Account Name
Account Number
Sort Code
SWIFT Code
IBAN
Client Money/Fiduciary Funds Account Details (if applicable)
Bank Name
Bank Address
Street Address City ZIP / Postal Code
Your Reference
Account Name
Account Number
Sort Code
SWIFT Code
IBAN

Summary of Completed Form
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Producing Broker Application Form