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Insurance Application
Service Forms
General questions
Broker Application
First name
*
Last name
*
Email
*
Additional comments / remarks / questions
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First name
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Last name
*
Email
*
Client ID
*
Case ID (optional)
Additional comments / remarks / questions
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Furthermore, you have read and accepted the
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First name
*
Last name
*
Email
*
Client ID (optional)
Your message
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Furthermore, you have read and accepted the
terms and conditions
related to your insurance plan.
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Company Information
Full company name
*
Nature of business
*
Registered company address
*
Date of Incorporation/Esablishment
*
Email
*
Phone no
*
Website
*
Date of Registration
*
Business Registration no
*
Broker ID (if available)
*
Owner Information
Please provide Name / Address / Telephone and Email of Owner(s) of the Business:
*
Representative/Employee information
Please provide (Name/Title/Email Address) of all Representative/Employees who will act as an intermediary for the products mentioned in this application/registration.
Company Insurance experience
Please provide a brief summary of the premium under management by your company / employees / representatives?
Medical Insurace Premium (USD)
Travel Insurance Premium (USD)
Personal Accident Insurance Premium (USD)
Other Insurance product provider references
Please provide information regarding two (2) other insurance product providers with whom your company currently has intermediary facilities in respect of private medical insurance (and from whom we may take references) including the date from which such agreement was originally made and the approximate gross written premium placed in the last 12 months.
Insurer One
Name of Insurer
Contact Person (Name/Email)
Date of Agreement
Gross Written Premium in the last 12 months (USD)
Insurer Two
Name of Insurer
Contact Person (Name/Email)
Date of Agreement
Gross Written Premium in the last 12 months (USD)
Bank account details
Bank name
Bank Address
Account name
Account currency
Account number
Bank sort code
IBAN
BIC/SWIFT
Confirmation of application details
*
I/ we apply to be granted an intermediary facility to represent Pacific Cross Insurance Company Limited as an intermediary. I/ we agree that, if this application is accepted, the appointment shall be governed by the terms of Pacific Cross Insurance Company Limited (including acceptance of the terms of its agency/intermediary agreement) in accordance with applicable law..
*
II/ we understand that references will be sought for my/ our application and to my/ our best knowledge and belief the above details are true and accurate. Any attempt to mislead or supply false information to Pacific Cross International (or appointed administrator) will result in the voiding of the agency/intermediary agreement.
*
You agree to our
privacy policy
.
Furthermore, you have read and accepted the
terms and conditions
related to your insurance plan.
Date of application
Name of the person who completed the application(*)
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