AN AGENT

FOR IPH

BECOME

Agency Application Form

Join our IPH family for a one-to-one personal approach

Thank you for your interest in applying for an agency with IPH Insurance. Please fully complete the online form below. Once your application has been submitted, you will receive a confirmation email. We will then endeavour to process your application as soon as possible.

Please feel free to contact us if you have any questions about the application process.

Contact Details

Name of Firm

Trading Name (if different from above)

Contact Name

Phone Number

Email Address

Registered Address

Registered Postcode

Company Details

Type of Company (please choose from the list below):

If a company, please state your:

a) Registration Number

b) Date Established

c) Authorised Share Capital

Please state the following details for each director/partner:

i) Director/Partner

ii) Director/Partner

iii) Director/Partner

iv) Director/Partner

Please give details of any other business activities that any of the directors/partners are engaged in:

Company Credentials

Are you a member of any professional organisation?

Yes No

If the answer to above is "Yes", please provide details:

Is your business registered as a member of the Financial Conduct Authority (FCA)?

Yes No

If the answer to above is "Yes", please provide your FCA registration number:

If your business is not registered as a member of the Financial Conduct Authority (FCA):

a) Have you or do you intend to apply?

Yes No

b) Has your application been refused?

Yes No

c) Are you regulated by any other recognised authority?

Yes No

What is your current trading status?

Independent Intermediary Company Agent

List your main general insurance company agencies (including Lloyd's syndicates)

Number of staff involved in insurance activities:

Are you authorised to hold client money?

Yes No

Has any insurer or Lloyd's Syndicate:

a) Withdrawn or cancelled your agency?

Yes No

b) Cancelled or reduced your credit facilities?

Yes No

If “Yes” to either of above, please provide more details:

Please give the name and details of your professional indemnity insurer:

Please upload your latest P.I. Certificate

Do you offer any sub-broking or sub-agent facilities?

Yes No

If the answer to above is “Yes”, please provide details:

Have you, or in the case of a registered company or partnership, has the company or partnership, or any of the directors or partners:

Been declared bankrupt?

Yes No

Been declared insolvent?

Yes No

Compounded with creditors?

Yes No

Been subject to a County Court Judgement?

Yes No

Been convicted of a criminal offence (other than for a driving offence) not treated as spent under the Rehabilitation of Offenders Act 1974?

Yes No

If “Yes” to any of above, please provide further details:

What is your total gross income?

What is your expected annual gross premium generated for IPH?

Declaration

The information provided above is complete and correct and will be incorporated into the Terms of Business Agreement. I/We undertake to notify IPH Insurance Services (UK) Ltd immediately if any of the above statements become incorrect, providing any details required regarding the change in circumstances.

Name:

Date:

Position:

If you require any assistance, please do not please do not hesitate to contact us if you have any questions about the application process.

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Agency Application Form

Join our IPH family for a one-to-one personal approach​

Policies

About

IPH Hub

Join our IPH family for a one-to-one personal approach