UK / EEA / US AND CANADA • The Unisure Group

INTERMEDIARY PROFILE

Full registered name of Intermediary: *

Trading name if different:

Was the entity ever registered under a different name? If yes, please record previous name(s):

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

Date incorporated: *

Registration Number: *

Place of incorporation: *

Website of corporation registering authority (e.g. Companies House, EBRA, etc): *

Registered Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Correspondence Address if different:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Unisure Representative Contact Name *

First

Last

Intermediary Principal Contact 1: *

First

Last

Position *

Position

Intermediary Principal Contact 1 Email: *

Email

Intermediary Principal Contact 1 Phone Option 1: *

Phone Option 1

Intermediary Principal Contact 1 Phone Option 2: *

Phone Option 2

Intermediary Principal Contact 2: *

First

Last

Position *

Position

Intermediary Principal Contact 2 Email: *

Email

Intermediary Principal Contact 2 Phone Option 1: *

Phone Option 1

Intermediary Principal Contact 2 Phone Option 2: *

Phone Option 2

Intermediary Administration Contact: *

First

Last

Position *

Position

Intermediary Administration Contact Email: *

Email

Intermediary Administration Contact Phone Option 1: *

Phone Option 1

Intermediary Administration Contact Phone Option 2: *

Phone Option 2

Company Telephone: *

Company Website:

Full name of each Director (or equivalent): *

First

Last

Full name of Director 2 *

First

Last

Full name of Director 3 *

First

Last

Full name of Director 4 *

First

Last

Full name of Director 5 *

First

Last

If there are more than five Directors, please list all additional Directors here:

Full name of each Shareholder / Beneficial Owner representing at least 10% of voting equity (please ensure that each Ultimate Beneficial Owner is identified): *

First

Last

Equity Share: *

Equity Share

Full name of Shareholder 2 *

First

Last

Equity Share: *

Equity Share

Full name of Shareholder 3 *

First

Last

Equity Share: *

Equity Share

Full name of Shareholder 4 *

First

Last

Equity Share: *

Equity Share

Full name of Shareholder 5 *

First

Last

Equity Share: *

Equity Share

If there are more than five Shareholders, please list all additional Shareholders here, noting their respective Equity Share:

REGULATORY AUTHORITY DETAILS

Name of Regulatory Authority: *

Regulatory Licence Number: *

Website of Regulatory Authority: *

Brief description of Regulatory Permissions: *

Do you have permission to handle Client Money / collect insurance premiums? *

Number of years operating as an insurance / financial intermediary: *

In which country or countries do you intend to sell our products? *

Please indicate each class of products you intend to offer your customers. *

Group Health (International)
Group Life & Disability (UK Market)
Group Life & Disability (International)
Individual Life (International)

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? *

If you answered yes to any of the above 4 questions, please provide more information.

DOCUMENTS TO BE UPLOADED *

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).

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, which may assist in evaluating this application.
We confirm that all answers given are true and correct.
We confirm that we will notify Unisure 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.
We authorise Unisure to conduct reasonable status enquiry searches about us.
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.
We agree that information provided by us in connection with this application will become part of the data held by Unisure. We understand that the information supplied, including personal data, will be used by Unisure for the purpose of establishing terms of business and for continuing administration.

Name of person responsible: *

First

Last

Position: *

Date: *