African Trade Insurance Agency (ATI) :: Broker Application Form

Broker Application Form

1.1 Applicant: Contact Details
Name Of Company
Physical Address
Street City Country
Postal Address *Website Address (optional)*
1.2 Applicant : Information
Country of incorporation (Domicile):
Registration Number:
Date of incorporation / establishment:
Legal Status (private, public, other):
Group of which the Applicant forms part (if applicable):
Name(s) and full address(es) of all of Applicant's shareholders with an ownership percentage of > 5% each:
Name: Full Address
Name: Full Address
Name: Full Address
Name: Full Address
Name: Full Address
Description of Applicant's business activity(ies):
List of Applicant's subsidiary(ies) and its(their) business activity(ies):
1.3 Applicant: Contact Person
Position:
Title: First Name: Last Name:
Telephone: Fax: Email:
Number of Years of Experience in the lines of business relevant to ATI (i.e. Political, non-commercial and commercial) insurance business;
An estimate of the total number of clients, the total number of projects and the aggregate amount of cover placed by the Applicant during the period mentioned under 1.4 (i) above; Number Of Clients: Number Of Projects: Aggregate Amount:
Referees I
Title: Name: Company Name:
Telephone: Fax: Email:
Referees II (optional)
Title: Name: Company Name:
Telephone: Fax: Email:
Referees III (optional)
Title: Name: Company Name:
Telephone: Fax: Email:
2. OTHER RELATIVE INFORMATION
2.1 Other relative information (optional), please specify:

3. ATTACHMENTS
3.1 Attachments
You are required to submit the documents listed below with your application: Broker's Licenses / Authorizations Annual Financial Reports / Financial Statements (for the last 3 years) Professional indemnity insurance policy The companies' business profile (containing organization chart and brief CV of key staff)
4. INSTRUCTIONS
4.1 Instructions
Once you generate the PDF form you will receive an email with instructions on how to edit and download this document.