Broker Application - Coverdrone

General Particulars

Name of Agent

Trading Name (if different)

Company Registration Number

Registered Address of Agent

Address Line 1

Address Line 2 (optional)

City

County Name

Postcode

Country

Contact Details

Phone Number

Please include your international dialling code

Email Address

Occupation

Occupation of Agent

Is Occupation Full Time or Part Time?

Full Time Part Time

Date Firm Established

Regulation

Is the agent authorised by their respective national financial/insurance regulatory body?

Yes No

Name of Regulatory Body

Regulatory Authorisation Number

Date First Authorised

Is the agent a member of any insurance broker/intermediary association?

Yes No

Name of Association

Professional Indemnity Insurance

Does the agent hold current and valid professional indemnity insurance?

Yes No

Insurer

Start Date

End Date

Limit of Indemnity

Please provide this amount in CAD

Excess

Please provide this amount in CAD

Does this policy cover the agent for activities relating to an agreement with Coverdrone?

Yes, this policy covers the agent No, this policy does not cover the agent

Please provide a copy of your current professional indemnity insurance certificate

Professional Indemnity Certificate

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Details of proprietors/partners/directors

Full Name

Date of Birth

Private Address

Address Line 1

Address Line 2 (optional)

City

County/State/Region

Country

Period of residence at the above address

All Partners/Directors must be declared

I need to declare another partner/director I do not need to declare another partner/director

We will register further partners/directors through secondary correspondance

Has any person, firm or company named in section 1 to 3, or anyone likely to be concerned with the business (either themselves, or any organisation in which they held a managerial position or controlling interest), at any time:

Been the subject of a receiving order?

Yes No

Please provide details of the receiving order.

Been the subject of an administration order?

Yes No

Please provide details of the administration order.

Entered into an arrangement with creditors?

Yes No

Please provide details of the credit arrangement

Been a director of a company which has been wound up?

Yes No

Please provide details of the company/situation

Been the subject of a court judgement for any debt?

Yes No

Please provide details of the court judgement

Had an application to represent or submit business to an insurance office refused, or a previous agency or terms of business agreement, cancelled?

Yes No

Please provide details of the application

Been convicted of a criminal offence (other than a motoring offence)?

Yes No

Please provide details of the criminal offence

Been subject to disciplinary proceedings of any form under any insurance industry code(s) of conduct/practice, or any other professional or regulatory body?

Yes No

Please provide details of the disciplinary proceedings

Declaration

Please agree to continue

I/We declare the information given in this form is correct to the best of my/our knowledge and belief. I/We undertake to advise Coverdrone Limited immediately of any significant changes to the information I/We have given in this form, including any changes in the directors, partners or proprietor, or the personnel managing day to day affairs, formal termination of any agency held with any other insurer/intermediary or any relevant change in our authorisation under the regulatory body stated in section 2. I/We agree that any personal data required or held by Coverdrone Limited relating to this application and any acceptance of it, including details of the director(s) and other officer(s) or the partners/proprietor and any employees, sub-agents, introducers, outsourcing providers or customers, may be disclosed to the other insurers, trade associations and regulatory bodies, for the purposes of assessing further applications for me/us, debt management and recovery and compliance with any regulatory codes/rules. I/We undertake to obtain all necessary consents for such disclosure of this data.

Yes, I have read and agreed to this declaration.

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General Particulars

Registered Address of Agent

Contact Details

Occupation

Regulation

Professional Indemnity Insurance

Details of proprietors/partners/directors

Private Address

Declaration

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