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UK / EEA / US AND CANADA
Please refer to the
Data Protection Policy
for details of how Unisure collects, holds and processes Personal Data.
Please enable JavaScript in your browser to complete this form.
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
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Correspondence Address if different:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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:
*
Do you have the correct permissions to distribute our products in the territory you operate?
*
Do you have permission to handle Client Money / collect insurance premiums?
*
Please Select
Yes
No
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?
*
Please Select
Yes
No
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?
*
Please Select
Yes
No
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?
*
Please Select
Yes
No
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 Select
Yes
No
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:
*
Submit