Broker Application Form
1.1 Applicant: Contact Details.
Name of Company (*)
Please type your full name.
Street (*)
Please type your full name.
City (*)
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Country
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Postal Address (*)
Please type your Postal Address
Website Address (optional)
Website Address (optional)
1.2 Applicant : Information
Country of incorporation (Domicile):
Registration Number:
Please type your full name.
Date of incorporation / establishment: (*)
dd.mm.yyyy
Legal Status
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Group of which the Applicant forms part (if applicable):
Group of which the Applicant forms part (if applicable):
Name(s) and full address(es) of all of Applicant's shareholders with an ownership percentage of > 5% each:
Name (*)
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Full Address (*)
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Name
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Full Address
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Name
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Full Address
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Name
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Full Address
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Name
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Full Address
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Description of Applicant's business activity(ies):
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List of Applicant's subsidiary(ies) and its(their) business activity(ies):
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1.3 Applicant: Contact Person
Position:
Please type Name.
Title (*)
Please type your full name.
First Name: (*)
Please type Nature of Business
Last Name:
Please type your full name.
Telephone: (*)
Please type your full name.
Fax
Please type Name.
Email
Please type your full name.
Number of Years of Experience in the lines of business relevant to ATI (i.e. Political, non-commercial and commercial) insurance business;
Please type Name.
An estimate of the total number of clients, the total number of projects and the aggregate amount of cover placed by the Applicant during the period mentioned under 1.4 (i) above
Number Of Clients:
Please type your full name.
Number Of Projects:
Please type your full name.
Aggregate Amount: (*)
Please type your full name.
Referees I
Title (*)
Please type your full name.
Name: (*)
Please type Nature of Business
Company Name:
Please type your full name.
Telephone: (*)
Please type your full name.
Fax
Please type Name.
Email
Please type your full name.
Referees II (optional)
Title
Please type your full name.
Name:
Please type Nature of Business
Company Name:
Please type your full name.
Telephone:
Please type your full name.
Fax
Please type Name.
Email
Please type your full name.
Referees III (optional)
Title
Please type your full name.
Name:
Please type Nature of Business
Company Name:
Please type your full name.
Telephone:
Please type your full name.
Fax
Please type Name.
Email
Please type your full name.
2. OTHER RELATIVE INFORMATION
2.1 Other relative information (optional), please specify:
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3. ATTACHMENTS
3.1 Attachments
You are required to submit the documents listed below with your application:
Broker's Licenses / Authorizations
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Annual Financial Reports / Financial Statements (for the last 3 years)
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Professional indemnity insurance policy
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The companies' business profile (containing organization chart and brief CV of key staff)
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