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Why Security Insured?
About Us
Fenchurch Law
Who We Cover
MANNED SECURITY
Close Protection Insurance
Door Supervision Insurance
Event Security Insurance
Security Guard Insurance
Dog Handler/Canine Security Insurance
SECURITY INSTALLATION
Access Control Insurance
CCTV Installers Insurance
Fire Alarm Installers Insurance
Intruder Alarm Installers Insurance
Locksmith Insurance
Sprinkler Insurance
What We Cover
Business Insurance
Public Liability Insurance
Employers Liability Insurance
Property Insurance
Motor Fleet Insurance
Commercial Legal Expenses Insurance
Directors & Officers Insurance
Personal Accident Insurance
Cash in Transit Insurance
Security Insurance Cover Extensions
Inefficacy & Contractual Liability
Products Inefficacy
Wrongful Arrest
Loss of Keys
Fidelity Guarantee
Financial Loss
Professional Indemnity Insurance
Health Insurance
Company or Group PMI
Individual PMI
International or Expat PMI
Life Insurance
Term Life Insurance
Key Man Insurance
Critical Illness Insurance
Group Life Insurance
Protection Insurance
Useful Links
Full Proposal Form
Examples of Claims
Report A Claim
FAQs
Knowledge Hub
Contact
Search for:
Security-Insured-Agency-Application-Form
Seb
2021-05-29T18:50:43+01:00
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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.
Company Details
Company Name
*
Trading Name (if applicable)
Country of Registration & Company Registration Number (if applicable)
Date Established
Organisation Type /Legal Status (please tick one)
Sole Trader
Private Limited Company
Unincorporated Association
Partnership
Public Limited Company
Limited Liability Partnership
Trading Address
Street Address
City
ZIP / Postal Code
Trading Telephone Number
Registered Office
Street Address
City
ZIP / Postal Code
Registered Office Telephone Number
Website Address
Principal Business Activity
Primary Contact Name and Email Address
*
Primary Contact Name at Security Insured
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
DD slash MM slash YYYY
Address
Position Held
Time with the firm
Person 2
Title/Forename/Surname
Date of Birth
DD slash MM slash YYYY
Address
Position Held
Time with the firm
Person 3
Title/Forename/Surname
Date of Birth
DD slash MM slash YYYY
Address
Position Held
Time with the firm
Regulatory Information
Are you registered with the FCA? (if yes, please provide your FCA number; if no, please provide your regulatory authority you are registered with below together with the related registration number)
Yes
No
FCA Number:
Other Regulatory Authority:
If you are an appointed representative please state your Principals name and FCA number:
Are you author ised to hold client money? (if yes, please indicate below whether it is held in a statutory or non-statutory account)
Yes
No
Indicate whether it is held in a statutory or non-statutory account
Please confirm that any RMAR and Client Money obligat ions have been met
Yes
No
Please confirm that all Financial Sanctions and Anti-Bribery & Corruption checks are in place with any exceptions having been fully investigated
Yes
No
Additional Company Information
Are you registered under the Consumer Credit Act? (if yes, please provide details below including licence number)
Yes
No
Please provide details including licence number
Are you registered under the Data Protection Act? (if yes, please provide details below)
Yes
No
Please provide details
Do you have more than one branch that requires agency facilities (excluding any Appointed Representatives)? If YES please provide full address and contact details below
Yes
No
Please provide full address and contact details
What software system do you currently use?
Are you a member of a Network or Affinity Group? (if yes, please specify the name and your membership status)
Yes
No
Please specify the name and your membership status
Professional Indemnity
Do you currently hold professional indemnity insurance? (if yes, please attach a copy of your P.I. certificate)
Yes
No
PLEASE NOTE THE APPLICATION WILL NOT BE PROCESSED WITHOUT THIS INFORMATION
Please attach a copy of your P.I. certificate
Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.
Sales Information
Please provide details of the Gross Written Premium (GWP) for the types of general insurance that you currently provide:
What is your total Gross Written Premium? £
What is the Commercial split? £
What is the Personal split? £
Business Continuity Planning
Do you have a business continuity plan in place that meets FCA requirements? (if yes, please provide details below of when this was last tested or when it is due to be tested)
Yes
No
Please provide details of when this was last tested or when it is due to be tested
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
Security Insured Products
Has any Director, Partner, Proprietor or Manager personally or by association:
If any of the below questions are answered as ‘Yes’, please provide further details in the bo x provided.
Been convicted of a crime involving dishonesty or breach of trust?
Yes
No
Please provide further details
Been charged with or convicted of a criminal offence other than a minor motoring offence in the last twelve months?
Yes
No
Please provide further details
Been disqualified under company law?
Yes
No
Please provide further details
Been found liable for negligence, fraud, wrongful trading or malpractice in connection with business activity?
Yes
No
Please provide further details
Been declared insolvent, bankrupt or made any similar arrangement with creditors?
Yes
No
Please provide further details
Been refused membership, censured, fined, disciplined, suspended, or expelled by any insurance industry regulatory body or trade association?
Yes
No
Please provide further details
Had a licence, authorisation or registration to conduct insurance business suspended, withdrawn or not renewed?
Yes
No
Please provide further details
Has your company been involved in any legal/court proceedings in the last 12 months?
Yes
No
Please provide further details
Is your firm or any Director, Principal, partner or key member of staff a specifically designated person under a financial sanction regime, or the subject of sanctions targets as designated by the US Office of Foreign Assets Control, the European Union, or HM Treasury?
Yes
No
Please provide further details
I hereby declare and affirm that I am duly authorised to submit this application and make this declaration on behalf of the Producing Broker (see ‘Terms’ below).
I declare on behalf of the Producing Broker that, to the best of my knowledge and belief, the information contained in and attached to this application information is accurate, complete, upto-date and purports to be comprehensive and not misleading.
I acknowledge and agree on behalf of the Producing Broker that any information provided pursuant to the application constituting personal data may be stored at and/or processed in accordance with our Privacy Statement (available on request).
I acknowledge that, where circumstances lead Security Insured to suspect bribery, corruption, or other financial crime in relation to business with the Producing Broker, additional due diligence may be carried out and further steps taken, including, the notification to the relevant authorities, status and credit checks using credit reference agencies, and other background checking, as deemed appropriate.
undertake to immediately advise Security Insured of any material changes to information contained within this questionnaire, being matters of which Security Insured would reasonably expect notice.
Name
Position
Signature
Date
Security Insured is a trading style and Appointed Representative of Movo Insurance Brokers Ltd.
Movo Insurance Brokers are authorised and regulated by the Financial Conduct Authority, authorisation number 515938.
Registered Office: 63 Cotmandene Crescent, Orpington, Kent, BR5 2RA Registered in England No: 07176446
Summary of Completed Form
Please check all details are correct before submiting
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Email
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