Broker Registration

Please complete this form as comprehensively as possible to assist us with assessing your application efficiently. All questions must be answered. If not applicable or relevant, please enter “N/A”. Once complete please hit submit.

Company Registration

Company Info

Do you hold any relevant memberships/subscriptions?

Do you provide any specialist schemes within the Insurance Market?

Do you place business provided by or on behalf of any sub agents/sub brokers/introducing brokers?

Please note the application is subject to the Company, Director
and/or owner of the applying brokerage having not been:

• charged with or convicted of any criminal offence other than a minor motoring office in the last 12 months.
• subject to a claim under your professional indemnity insurance policy in the last 10 years.
• a party to any legal proceedings or action, nor has any such actions pending in which you or the Company have been named as a defendant in the last 12 months.
• subject to liquidation, receivership, bankruptcy or administrative order.
• entered into or proposes to enter into an agreement or assigned with creditors or otherwise acknowledged insolvency.
• disqualified under Company Law.
• criticised, fined, disciplined, suspended or expelled by any insurance industry trade association or regulatory body.
• refused, suspended, withdrawn or not renewed a licence or authorisation to conduct insurance business.
• asked to resign excluding redundancy or been dismissed from any previous office or employment.
• or currently act as a Directors of any other financial services sector organisation or organisation that may provide ser-vices under this agreement?

Declaration

In consideration of Corin assessing our application, we, the applicant, confirm that after conducting reasonable enquiries, the information in this application form is accurate and complete to the best of our knowledge and belief. We acknowledge that if we have provided any false or misleading information in connection with this application, it may lead to the rejection of the application.

We also confirm that the information provided is true, accurate and up to date as at the time of the application. We will notify Corin if there are any changes in the information given in this application form before the application is approved.