Agency Application | Gem Underwriting

Please complete all sections below before submitting.

Part 1: Firm's Details

Name of Firm *

Trading Title *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Contact First Name *

Contact Last Name *

Phone *

Email *

Website / URL

Part 2: Legal & Regulatory Details

Main Business Activities *

Legal Status *

If 'OTHER', please provide details

Date Established *

Country of Registration *

Registration Number

Parent Company

Subsidiary Companies

Are you registered with the Financial Conduct Authority (FCA)? *

If YES, please provide your Firm Reference Number

Do you have in place appropriate procedures to counter the risk of your firm becoming involved in fraud, bribery or corruption? *

If YES please upload a copy of your policy/procedures

Drop your file here or click here to upload You can upload up to 1 files.

Only PDF file type allowed. Max File Size 5MB.

Do you have in place Professional Indemnity/Errors & Omissions Insurance? *

If YES please provide a copy of your latest Schedule/Certificate

Drop your file here or click here to upload You can upload up to 1 files.

Only PDF file type allowed. Max File Size 5MB.

Part 3: Directors & Personnel

Details of all Directors, Partners & Financially Associated Persons

Name

Position

Time with Firm (Years, Months)

Name

Position

Time with Firm (Years, Months)

Name

Position

Time with Firm (Years, Months)

Name

Position

Time with Firm (Years, Months)

Total Number of Employees

Total Number of Producers

Has your firm or any Director, Partner or financially associated person(s) been convicted of a crime involving dishonesty or breach of trust? *

If YES, please provide details

Are you authorised to hold client money? *

If YES, has a CASS audit has taken place? *

If NO please provide details below of how you deal with client premiums.

Account Name *

Account Number *

Account Type *

Statutory Trust
Non-Statutory Trust

Sort Code *

SWIFT/IBAN Code

If YES please upload a copy of your latest Financial Accounts.

Drop your file here or click here to upload You can upload up to 1 files.

Only PDF file type allowed. Max File Size 5MB.

Part 5: The Firm's Insurance Business

The Firm's Total Gross Written Premium (£) *

Estimated annual GWP to be placed with Gem Underwriting Agency Ltd (£) *

Please provide details below of the person(s) who will be responsible for the day-to-day trading with us.

Please provide brief details of how you heard about us.

Declaration

I hereby declare and affirm that I am duly authorised to submit this application and make this declaration on behalf of the firm. I declare on behalf of the firm that to the best of my knowledge and belief, the information contained in and attached to this application is accurate, complete and up to date. I acknowledge that where circumstances lead Gem Underwriting Agency Ltd to suspect fraud, bribery, corruption or other financial crime in relation to business with the firm, additional due diligence may be carried out and further steps taken, including but not limited to, the notification to the relevant authorities and background checks, as deemed appropriate by Gem Underwriting Agency Ltd policies and procedures. I confirm that I have read and understood the above declarations.

I confirm that by ticking this box and typing my name below, I am electronically signing this declaration. *

I confirm that I am duly authorised to submit this application on behalf of the firm and that the information provided is true and complete.

Name

Position

Date

Agency Application Form

Please complete all sections below before submitting.

Part 1: Firm's Details

Part 2: Legal & Regulatory Details

Part 3: Directors & Personnel

Part 4: Client Money & Bank Accounts

Part 5: The Firm's Insurance Business

Declaration