Introducing Business

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I have an FCA number I do not have an FCA number

Select one of these 2 Options

I am Directly Authorised (DA) I am an Appointed Representative (AR)

FCA Number:

First Name:

Surname

Company Name:

Company Address:

Company Type

Phone number:

Email:

How did you find us?

Terms & Conditions

Accept Terms & Conditions (please tick)

Terms & Conditions Accepted

Accept Terms & Conditions (please tick)

Terms & Conditions Accepted

Accept Terms & Conditions (please tick)

Terms & Conditions Accepted

1. Who is your principal firm and what is their FCA number?

2. Are you, or have you ever been, the subject of, or are you aware of any intention to begin against you, either in the UK or elsewhere:

2a. any civil proceedings, or litigation, including judgement debts or arbitration?

YES NO

Please give details:

2b. any bankruptcy proceedings, or proceedings for the sequestration of your estate, including entering into a deed of arrangement, an individual voluntary arrangement (or in Scotland a trust deed) in favour of your creditors, or other composition, or arrangement with creditors?

YES NO

Please give details:

2. Are you, or have you ever been, the subject of, or are you aware of any intention to begin against you, either in the UK or elsewhere:

2a. any civil proceedings, or litigation, including judgement debts or arbitration?

YES NO

Please give details:

YES NO

Please give details:

3. If you have been the subject of any judgement debts under a court order, have you:

3a. any such debts still outstanding, whether in full or in part?

YES NO

Please give details:

3b. failed to satisfy any such debts within one year of the making of the order?

YES NO

Please give details:

3. If you have been the subject of any judgement debts under a court order, have you:

3a. any such debts still outstanding, whether in full or in part?

YES NO

Please give details:

3b. failed to satisfy any such debts within one year of the making of the order?

YES NO

Please give details:

4. Have you ever, either in the UK or elsewhere:

4a. been refused entry to any profession or vocation, or been dismissed or requested to resign from any office or employment or from any fiduciary office or position of trust, whether or not renumerated?

YES NO

Please give details:

4b. been refused, or restricted in, the right to carry on any trade, business or profession for which specific licence, authorisation, registration, membership or other permission is required?

YES NO

Please give details:

4c. been disqualified by a court from acting as a director of a company or from acting in a management capacity or from conducting the affairs of any company, partnership or unincorporated association?

YES NO

Please give details:

4. Have you ever, either in the UK or elsewhere:

YES NO

Please give details:

4b. been refused, or restricted in, the right to carry on any trade, business or profession for which specific licence, authorisation, registration, membership or other permission is required?

YES NO

Please give details:

YES NO

Please give details:

5. Have you or has any partnership or unincorporated association of which you have been a controller, director or partner:

5a. been refused, had revoked, restricted or terminated any licence, authorisation, registration, notification, membership or other permission granted by any such body?

YES NO

Please give details:

5b. been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or intervention action of any such body?

YES NO

Please give details:

5c. resigned, or been asked to resign, from any such body or, after making a notification or application for any licence, authorisation, registration, membership or other permission granted by any such body, decided not to proceed with it?

YES NO

Please give details:

5d. been the subject of any civil action that has resulted in a finding against you or it by a court?

YES NO

Please give details:

5e. knowingly been the subject of an investigation into allegations of misconduct or malpractice in connection with any business activity?

YES NO

Please give details:

5. Have you or has any partnership or unincorporated association of which you have been a controller, director or partner:

5a. been refused, had revoked, restricted or terminated any licence, authorisation, registration, notification, membership or other permission granted by any such body?

YES NO

Please give details:

5b. been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or intervention action of any such body?

YES NO

Please give details:

YES NO

Please give details:

5d. been the subject of any civil action that has resulted in a finding against you or it by a court?

YES NO

Please give details:

5e. knowingly been the subject of an investigation into allegations of misconduct or malpractice in connection with any business activity?

YES NO

Please give details:

6. Has any company, partnership, or unincorporated association of which you are or have been a controller, director, partner, manager or company secretary, in the UK or elsewhere, at any time during your involvement:

6a. been put into liquidation, had a petition presented, or a meeting summoned to consider a resolution, to wind up the company, or been wound up, had a petition for bankruptcy presented, or been declared bankrupt?

YES NO

Please give details:

6b. ceased trading in circumstances in which one or more creditors did not receive full payment, had a receiver or administrator appointed, or entered into (or made any proposal to enter into) any arrangement with creditors, or made a trust deed for creditors, or been dissolved?

YES No

Please give details:

YES No

Please give details:

YES NO

Please give details:

7. Have you ever, or has any company, partnership, or unincorporated association of which you are or have been a controller, director, partner, manager or company secretary, in the UK or elsewhere, at any time during your involvement:

7a. been adjudged by a court liable for any fraud, misfeasance, wrongful trading or other misconduct towards a Regulatory Authority or towards any members or creditors of a Regulatory Authority?

YES NO

Please give details:

7b. been investigated by an inspector appointed under companies or any other legislation, or required to produce books and papers to the Secretary of State?

YES No

Please give details:

7a. been adjudged by a court liable for any fraud, misfeasance, wrongful trading or other misconduct towards a Regulatory Authority or towards any members or creditors of a Regulatory Authority?

YES NO

Please give details:

7b. been investigated by an inspector appointed under companies or any other legislation, or required to produce books and papers to the Secretary of State?

YES NO

Please give details:

Refer Home Insurance

Central Derby location for Safe&Secure - located on Pride Park, East Midlands

Central Derby location for Safe&Secure - located on Pride Park, East Midlands

Customer Choice

5 Star Defaqto rates policies

Not a Call Centre - “Fully Advised Service”

Panel of 32 Insurance Products including

Customer Choice

5 Star Defaqto rates policies

Not a Call Centre - “Fully Advised Service”

Panel of 32 Insurance Products including

Access to your very own Broker Suite

Leads

Contact History

Written Policies

Pipeline Cases

Commission

Access to your very own Broker Suite

Leads

Contact History

Written Policies

Pipeline Cases

Commission