Vasek Insurance - Account Application

Company Details

How did you hear about us? *

Full Legal name of company *

Is the trading name different from the legal company name? *

Yes

Date of birth (Only for sole traders)

Address line 1 *

Address line 2

City/Town

Postcode *

Country *

Main point of contact name *

Country of domicile *

Phone number *

Main point of contact email *

Website

Company Type *

Limited

Limited - liability partnership

Sole Traders

Partnership

Other (please specify)

Is this the registered office address? *

Yes

Registered address line 1 *

Registered Address line 2

Registered City/Town

Registered address postcode *

Registered country *

Company Registration Number (Companies House) *

Country of Registration *

Name of Financial Regulator (i.e. FCA) *

Company Financial Regulator Number (FCA Number) *

Date business established *

Parent company (if applicable)

Subsidiary Companies (if applicable)

Affiliated Companies (if applicable)

Total number of employees *

How many branches does your company have? *

Appointed representatives *

Shareholder Details

Main shareholder details:

Title *

First name *

Last name *

Date Of Birth *

Address line 1 *

Address line 2

City *

Postcode *

Time connected with the firm *

Years

Percentage of shareholding *

Add shareholder Remove shareholder

Director Details

Main director details:

Title *

First name *

Last name *

Date Of Birth *

Address line 1 *

Address line 2

City *

Postcode *

Position *

Time connected with the firm *

Years

Add director Remove director

Company History

Please answer all questions in full - Required: *

Has your firm or any director, principal, partner or controller, personally or by association of any of the following:

Been convicted of a crime involving dishonesty or breach of trust? *

Yes

Been disqualified under company law? *

Yes

Been found liable for negligence, fraud, wrongful trading or malpractice in connection with business activity? *

Yes

Been declared insolvent, bankrupt or made any similar arrangement with creditors? *

Yes

Been refused membership, censured, fined, disciplined, suspended, or expelled by any insurance industry regulatory body or trade association? *

Yes

Had a licence, authorisation or registration to conduct insurance business suspended, withdrawn or not renewed? *

Yes

Is your firm or any director, principal, partner, controller or key member of staff a specially designated person under a financial sanction regime, or the subject of sanctions targets as designated by the US Office of Foreign Assets Control, the European Union, or HM Treasury? *

Yes

Corruption Questions

Do you have in place appropriate procedures to counter the risk of your firm becoming involved in bribery or corruption? *

Yes

Does any government official, government employee, or government entity have any ownership interest, other financial interest, or management role in your firm? *

Yes

Has any of the persons who hold company shares or directorships, or any family member of these persons, currently or previously held any position of responsibility within any government, government agency, any enterprise owned in whole or in part by a government, or any international organisation? *

Yes

Do you have adequate controls and procedures in place to ensure all taxes are accounted for and paid appropriately, including VAT and Insurance Premium Tax (where relevant)? *

Yes

Please provide the following required documents.

Group structure chart *

Professional Indemnity/Errors & Omissions Insurance Certificate (or equivalent) *

Directors’ & Officers Insurance Certificate

List of company directors & shareholders (with over 25% shareholding)

Fidelity insurance

If non UK company – evidence of regulatory authorisation

Bank Details

Please answer all questions in full - Required: *

Full Legal Name of Bank *

Bank Address line 1 *

Bank Address line 2

Bank City/Town *

Bank Postcode *

Bank Country *

Your Reference *

Account Name *

Account Number *

6 Digit Sort Code

Currency *

Additional Details

Have your systems and controls regarding the handling of client money/fiduciary funds been audited by a third party? *

Yes

Is there any circumstance which has occurred, subsequent to the audited accounts, which could prejudice the financial position of your firm? *

Yes

Any other Information to be declared?

Important Notice

I hereby declare and affirm that I am duly authorised to submit this application and make this declaration on behalf of the Trading Partner.
I declare on behalf of the Trading Partner that, to the best of my knowledge and belief, the information contained in and attached to this application (“Information”) is accurate, complete, up-to-date and purports to be comprehensive and not misleading.
I acknowledge and agree on behalf of the Trading Partner that any Information provided pursuant to the application constituting Personal Data may be stored at and/or processed in accordance with AJG's Privacy Statement (available on AJG's website www.ajginternational.com/privacy-and-cookies-policy).
I acknowledge that, where circumstances lead AJG to suspect bribery, corruption, or other financial crime in relation to business with the Trading Partner, additional due-diligence may be carried out and further steps taken, including, the notification to the relevant authorities, status and credit checks using credit reference agencies, and other background checking, as deemed appropriate.

By agreeing to the declaration below I confirm that I have read and understood the above declarations

I agree*

New Account Application

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