Broker Application Form

The information contained herein is provided to ATI in order to facilitate the evaluation of a Broker as one eligible to refer business to ATI acting on behalf of clients. The application is considered complete when all other required information is provided. False or misleading statements and information provided to ATI, may result, at ATI's sole discretion, in the removal of the Broker from ATI's list of eligible Brokers. This form is duly completed and signed and is being submitted along with copies of broker's license, financial statements, professional indemnity insurance policy and the companies' business profile (containing an organization chart and brief CV of key staff). Please note, if you are registered under ATI's Broker Programme, that your continued registration under ATI's Broker Programme is, of course, contingent on your compliance with the standards for registered brokers published on ATI's website (see ATI's list of brokers).
1.1 Applicant: Contact Details.
Name of Company*
Street*
City*
Country
Postal Address*
Website Address (optional)

1.2 Applicant : Information
Country of incorporation (Domicile)
Registration Number
Date of incorporation / establishment*
DD slash MM slash YYYY
Legal Status
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:
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
1.4 Applicant's Experience
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*

2. OTHER RELATIVE INFORMATION
2.1 Other relative information (optional), please specify
3. ATTACHMENTS
3.1 Attachments - 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)
Broker's Licenses / Authorizations
Accepted file types: pdf, docx, xls, xlsx, Max. file size: 10 MB.
Annual Financial Reports / Financial Statements (for the last 3 years)
Accepted file types: pdf, docx, xls, xlsx, Max. file size: 10 MB.
Professional indemnity insurance policy
Accepted file types: pdf, docx, xls, xlsx, Max. file size: 10 MB.
The companies' business profile (containing organization chart and brief CV of key staff)
Accepted file types: pdf, docx, xls, xlsx, Max. file size: 10 MB.