Broker Application form
Please take note that this application cannot be processed if ALL fields and pages are not completed in full.
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 Choose
Registration no (if applicable) or details if ‘other’
Please list the names and I.D. numbers of all directors / members/ sole proprietors
Name ID
Name ID
Name ID
Name ID
Please list the names, I.D. numbers or company registration number of all share holders
Name ID
Name ID
Name ID
Name ID
Please list the names, I.D. numbers and e-mail addresses of all representatives that would be marketing
CIA products
Name ID
Name ID
Name ID
Name ID
COMMERCIAL AND INDUSTRIAL ACCEPTANCES (PTY) LTD | Reg. No. 2000/019340/07 | VAT No. 4540194349
Authorised Financial Services Provider Licence No. 13890 | www.cia.co.za
Directors: DM Haig | VJ Hayter | IE Ismail | J Pienaar | SY van Schoor
Underwriting Managers for Compass Insurance Company Limited | Reg. No. 1994/003010/06 | VAT No. 4150143289 | FSP No. 12148
Branches in: Johannesburg | Durban | Cape Town | Bloemfontein | Port Elizabeth | Pretoria
Company Details
Have any of the persons listed above, or has any organisation in which they held a management position been
placed in provisional or final liquidation, receivership or been placed under provisional or final judicial
management, or been provisionally or finally sequestrated or entered into arrangements with creditors or are
any such matters still pending? If YES, please provide full details.
Have any of these persons been convicted of any criminal offence during the past 5 years? If YES, please
provide full details.
Is there any civil or criminal litigation pending against any of the person mentioned above or against the
applicant? If YES, please provide full details.
Have any of these persons ever had any agency or an agency application declined, terminated or granted on
special terms? If YES, please provide full details.
Contact Details
Physical address from which business is conducted
Business tel Cell
Fax Email
Postal and code
Website
Other Contact Details
Main contact person
Email
Underwriting contact person
Email
Claims contact person
Email
Page 2 | Broker Application Form
Other Contact Details
Accounts contact person
Email
Membership Details
State any insurance/broker/underwriting association related membership
Branch
Association Membership no.
Association Membership no.
Banking Details
Bank Branch
Branch code Type of account
Account number Name of account holder
Have you changed bankers over the last 2 years, if Yes please advice
Bank Name of account holder
Branch Account number
Facility/Contract Details
Below, list the detail as requested of the three insurance Companies and/or Underwriting Agencies with whom
most of your business is placed. Please note that all three need to be completed 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
Page 3 | Broker Application Form
Facility/Contract Details
List the names only of any other insurance company and/or underwriting agency with whom you place
business
1 2
3 4
5 6
7 8
Do you currently have a Compass facility through any other Compass Underwriting Manager? If YES, Please
provide details below.
Tax Status
Is the Company a registered taxpayer?
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 the terms of FAIS
FSP licence number
Category (e.g. Cat I / II / IIA III / IV)
What type of financial service the FSP is registered to provide
Please provide sub-catogory 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
If the answer is YES, please provide details of such conditions
Name of registered Compliance Officer
Email
Business tel Cell
Cover Details
Please attach supplementary proof (i.e. policy schedule or proof of cover)
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
Page 4 | Broker Application Form
Cover Details
Please attach supplementary proof (i.e. policy schedule or proof of cover)
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
Who is covered under the PI policy, e.g. only Directors, all staff? Please specify
Suitable Fidelity Insurance / Bank Guarantee (compulsory if the FSP receive premiums or hold assets on
behalf of client 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% if its annual income form 1 (one) client only
Choose
The Company employs 3 (three or more full time employees who are not share holders or members/directors
of the Company
Choose
General Declaration
The information contained herein is true and correct and shall form part of the agreement to be concluded
between Compass, the Underwriting Manager and the independent intermediary
Proposal/declarations complete by
Signature Date
The acceptance of this proposal is subject to the final approval of Compass Insurance. Compass Insurance will
not accept responsibility for cover until confirmation has been issued and the agreement between the parties
have been concluded
Office Use
Item Checked by Approved by
Date received at Compass
Proof of PI attached Choose
Prof of IGF and FI attached Choose
Page 5 | Broker Application Form
