Please complete the online form below, or alternatively download the PDF version and email it to us at info@compass.co.za.

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BECOME A BROKER

We look forward to welcoming you to the Compass Insure broker community.

Underwriting Management Agency

Date

Processed by (UMA staff member)

Inception date of facility requested

COMPANY DETAILS


Name in full, including current trading title, if any

Previous trading names, agencies or brokers with whom you have been associated

Type of business:

Private Company (Pty) Ltd
Personal Liability Company (Inc.)
Close Corporation (CC)
Sole Proprietor
Other

Please list the names and I.D. numbers of all directors / members / sole proprietors

Please list the names, I.D. numbers or company registration numbers of all shareholders

Please indicate if any of the persons listed above or any organisation in which they have held a managerial position has been placed in provisional or final finally sequestrated or entered into arrangements with creditors or are any such matters still pending?

Yes
No

Have any of the persons listed above been convicted of any criminal offence during the past 5 years?

Yes
No

Is there any civil or criminal litigation pending against any of the persons mentioned above or against the applicant?

Yes
No

Have any of these persons ever had any agency or an agency application declined, terminated or granted on special terms?

Yes
No

CONTACT DETAILS


Physical address from which business is conducted

Business tel

Cell

Fax

Email

Full postal address

Website

CONTACT DETAILS FOR APPLICANTS


Main contact person

Email

Underwriting contact person

Email

Claims contact person

Email

Accounts contact person

Email

MEMBERSHIP DETAILS


Please list any relevant memberships, including insurance/broker/underwriting association memberships:

BANKING DETAILS


Bank

Branch

Branch code

Type of account

Account number

Name of account holder

Have you changed bankers over the last 2 years?

Yes
No

If yes, please advise the following:

Bank

Name of account holder

Branch

Account number

FACILITY / CONTRACT DETAILS


Please provide details of the top three insurance companies and/or Underwriting Management Agencies with whom the majority of your business is placed. Complete all fields in full.

Company name

Branch

Contact person

Contact number

Period of agreement


Company name

Branch

Contact person

Contact number

Period of agreement


Company name

Branch

Contact person

Contact number

Period of agreement


List the names only of any other insurance company and/or underwriting agency with whom you place business:

Do you currently have a Compass Insure facility through any other Compass Insure Underwriting Management Agency?

Yes
No

TAX STATUS


Is the Company a registered taxpayer?

Yes
No

Income tax number

VAT registration number

FINANCIAL ADVISORY AND INTERMEDIARY SERVICES ACT


Please note that your application cannot be approved if you have not registered correctly in terms of FAIS.

FSP licence number

Category (e.g. Cat I / II / IIA III / IV)

Please specify the type of financial services that the stated FSP is registered to provide. Please provide sub-category product details e.g. 1.2 (short-term insurance personal lines); 1.6 (short-term insurance commercial lines).

Are there any other conditions applicable for licence categories?

Yes
No

Name of registered Compliance Officer

Email

Business tel

Cell

COVER DETAILS


Please email supplementary proof (i.e. policy schedule or proof of cover) to info@compass.co.za

Professional Indemnity Cover (Compulsory for all FSP's in terms of the Notice on Requirements for Professional Indemnity and Fidelity Insurance Cover for Providers, published in Board Notice 123 of 2009)

Excess structure

Underwriter

Limit of indemnity

Policy number

Expiry date


I.G.F. Cover (compulsory if the intermediary is mandated as a credit intermediary to receive and hold premium in terms of Section 45 of the Short-term Insurance Act read with Regulation 4 thereto)

Excess structure

Underwriter

Limit of indemnity

Policy number

Expiry date

Please specify to which personnel the PI policy applies, e.g. only Directors of the company or to all staff?


Suitable Fidelity Insurance / Bank Guarantee (compulsory, if the FSP receives premiums or holds assets on behalf of clients in terms of the Notice on Requirements for Professional Indemnity and Fidelity Insurance Cover for Providers, published in Board Notice 123 of 2009)

Excess structure

Underwriter

Limit of indemnity

Policy number

Expiry date

DECLARATION - PERSONAL SERVICE PROVIDER IN TERMS OF THE INCOME TAX ACT


The Company does not derive more than 80% of its annual income from 1 (one) client only?

Yes
No

The Company employs 3 (three) or more full time employees who are not shareholders or members/directors of the Company?

Yes
No

GENERAL DECLARATION


The information contained herein is true and correct and shall form part of the agreement to be concluded between Compass Insure, the Underwriting Management Agency and the applicant.

Proposal / declarations completed by

Date

I confirm that the information given in this form is true, complete and accurate.