SES Unisure Intermediary Application

COUNTERPARTY DETAILS

Counterparty's full legal entity name: *

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

Date established: *

Company registration number *

Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Registered Address if different:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone: *

Web address: *

Unisure/SES Zambia contact name *

First

Last

Principal contact name: *

First

Last

Principal contact email: *

Principal contact phone: *

Please provide details of group structure (if applicable) and proof of the Counterparty's most recent filing with governing entities (tax and regulatory authorities if applicable):

Click or drag files to this area to upload. You can upload up to 4 files.

Please tick to confirm inclusion: *

I have uploaded the necessary documents

REGULATORY STATUS

Please provide details of the applicable insurance regulator: *

Please provide the web address of the applicable insurance regulator: *

Please provide the firm’s allocated reference number from applicable regulator: *

Has the Counterparty ever been adjudged by a court liable for fraud, misfeasance, wrongful trading or other misconduct? *

Has the Counterparty ever knowingly been the subject of an investigation into misconduct or malpractice? *

Has the Counterparty ever been subject to a disciplinary proceeding by any trade, profession or regulatory body? *

If you answered yes to any of the above 3 questions, please provide more information:

PROFESSIONAL INDEMNITY INSURANCE

We are required to obtain details and evidence of your Professional Indemnity / Errors and Omissions Insurance Policy.

Insurer Name: *

Start Date: *

End Date: *

Limit of Indemnity: *

Excess: *

Please provide details of any claims made within the last five years or any circumstances that may give rise to claim: *

Please provide a copy of your current Professional Indemnity / Errors and Omissions Insurance Policy: *

Click or drag files to this area to upload. You can upload up to 4 files.

Please tick to confirm inclusion: *

I have uploaded the necessary documents

GENERAL BUSINESS CONDUCT

Has the Counterparty had a potential trading partner refuse it a terms of business agreement, or had an existing one revoked, in the last year? *

If Yes, why?

Does the intermediary outsource any insurance related activities to third parties? *

If Yes, please provide further details?

ACCOUNT PROFILE

Please indicate the type of arrangement sought with SES Zambia (please select those which are applicable): *

Broker
Independent Agent
Tied Agent
Introducer/Lead Generator

Please indicate the classes of business for which placing is currently sought (please select those which are applicable): *

Group Health
Individual Health
Group Life & Disability
Individual Life

BANK ACCOUNT INFORMATION

For settlement of commissions and/or introducer fees (as appropriate to your status and the TOBA / Introducer Agreement provided by us).

Bank Name: *

Bank Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Account Number / IBAN: *

BIC: *

Sort Code:

Routing Code:

Please provide a letter from the bank with your details: *

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DECLARATION

We confirm that to the best of our knowledge and belief the information contained in this questionnaire and attachments are correct.

Please ensure you have attached the following: *

A copy of group structure chart (if applicable)
A copy of the bank letter
A copy of the Professional Indemnity insurance certificate

We confirm that we have systems and controls in place to ensure that appropriate financial sanctions screening is undertaken on all proposers prior to inception of cover. This shall apply whether or not we, or sub-intermediaries appointed by us, are dealing directly with the insured. *

Agreed

Name of person responsible: *

First

Last

Title: *

Date: *