Initial Setup

Broker Type *

Type of Broker *

Name of the broker Group *

Sponsoring DUAL Team *

Dual Underwriter Contact Name *

Please give more detail on the sponsoring DUAL Team

Section 1 - General Information

Full Legal Name of the Firm *

Trading names, assumed names or business names:

Registered Office Address *

Registered Office Country *

Trading Address

Accounting Address (including Branches and Accounting Offices) *

Accounting Contact Email *

Contact Name *

Contact Phone Number *

Contact Email *

Website *

Year Firm Established *

Names of directors/partners/principals

Status of Firm *

Limited
Sole Trader
Partnership
Listed
Corporation

Company Registration No. *

Amount of premium handled by the firm

Estimated GWP to DUAL

Classes of business to be shown *

Accident & Health
Financial Lines
Legal Indemnities
Liability
Marine
Motor
Property
Reinsurance
Other Lines

Please confirm additional lines of business

Is the Firm party to any agency agreements or binding authorities? *

Yes
No

Please provide details

Is the firm a Lloyds's approved broker *

Yes
No

Section 2 - Regulatory / Licence Status

Name of the agency or government authority by whom the Firm is registered or regulated *

Website address of the regulating body *

Country *

Registration Number *

Current Principal Name *

Current Principal Registration Number *

Current Principal Registered Address *

Section 3 - Sanctions / Financial Crime

Does the Firm currently have in place procedures to ensure it is not trading directly or indirectly with designated individuals or entities, goods or countries subject to international sanctions or embargoes? *

Yes
No

Please indicate below the lists screened against:

OFAC
UN
EU
UK HMT

Other - please specify:

Please indicate frequency of screening?

New Client
Prior to payment
Daily
Monthly
Quarterly
Annually

If using an automated system(s), which system does the Firm use?

Does the Firm currently have in place policies and procedures to prevent Financial Crime?

Yes
No

If yes, select which of the following they cover

Money Laundering
Insurance Fraud
Information Security
Bribery & Corruption
Business Continuity Plan
Data Protection Policy

Do you have a third party due diligence process in place? *

Yes
No

Please provide details:

If no, is the Firm planning to introduced procedures in the future? *

Yes
No

If yes, please provide details

Section 4 - Insurance Monies

Do you require a premium finance or instalment facility for your Consumer customers?

Yes
No

Do you require a Risk Transfer ToBA?

Yes
No

Do you hold client money permissions?

Yes
No

Are premium or other funds owned by (re)insureds and/or (re)insurers (fiduciary funds) kept in separate accounts to other funds i.e. not mingled with other funds? *

Yes
No

Once in receipt of a premium is it deemed that the insurer has been paid? *

Yes
No

Are these accounts trusts accounts i.e. would the beneficial owners be protected in the event of the Firm's insolvency?

Yes
No

Has the Firm (or its principal shareholders, directors, officers, employees or persons representing the Firm) or affiliated organisation or any predecessor business filed for bankruptcy in the past five years?

Yes
No

If Yes, please describe the circumstances

Declaration

The above statements are, having made all reasonable enquiries, true to the best of the knowledge and belief of the undersigned.
The Firm and its directors, officers, and employees or persons representing the Firm holds or will obtain all necessary authorisations / licences in all appropriate jurisdictions to enable it to conduct business with DUAL.
The Firm will advise DUAL of any subsequent material change to the above information and agrees to provide DUAL with latest Professional Indemnity insurance details and financial statements.
The Firm hereby consents to DUAL performing financial checks as part of their due diligence to assess the creditworthiness of the Firm.

Declaration

The above statements are, having made all reasonable enquiries, true to the best of the knowledge and belief of the undersigned.
The Firm and its directors, officers, and employees or persons representing the Firm holds or will obtain all necessary authorisations / licences in all appropriate jurisdictions to enable it to conduct business with DUAL.
The Firm will advise DUAL of any subsequent material change to the above information and agrees to provide DUAL with latest Professional Indemnity insurance details and financial statements on an annual basis.
The Firm hereby consents to DUAL performing financial checks as part of their due diligence to assess the creditworthiness of the Firm.

Please accompany all original supporting documents with translations in English.

The Firm's latest financial statements - 2 years *

Evidence of the Firm's Professional Indemnity Insurance *

Date of Expiry of Professional Indemnity Insurance *

A copy of the Firm's client Toba for review and our records *

Copies of any current regulatory/trading licences *

Copies of the Firm's Insurance Bank Account Details (to be provided on the Firm's headed stationery) *

Submit

Submitter Name *

Position Held *

Date *