Composite Legal Expenses
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Agency Application Form

Welcome to the IQ Online web-site. Before you can start writing business with us, we need to find out a few details about you.

Please complete this simple registration form, accept the Declaration and your new agency number and password will be sent to you within the hour. Thank you.

General Details
Company Name *
Trading Name(s)
1st line of address *
2nd line of address
Town/City
Postcode *
Telephone *
Fax Number
Email
Principal Contact Forename
Principal Contact Surname *
Position in organisation
Parent Organisation if any

Type of organisation *
(Select One)

Limited Company (Ltd) Partnership
Sole Trader Other

If other please explain

Nature of business *
(please select the type which best reflects your main business activity)

Lloyd's Broker Solicitor
Independent Intermediary Claims Management Company
Bank or Building Society IFA
Retailer Estate Agent
Travel Agent Accountant
Loss Adjuster Other

If other please explain

FSA Status & Regulation *
(Please select your status in relation to the FSA)
 
Minded to Authorise
Authorised
FSA Firm Number (if authorised)
Exempt (give details)
Appointed Representative
(give details)
Introducer Appointed Representative (give details)
Are you regulated by any other regulatory body?
If yes, please name the body or bodies

More... *
Number of offices from which you engage in General Insurance.
Number of employees selling or advising on General products or services.
Do you currently sell pre-paid legal expenses insurance for personal customers?
Do you currently sell pre-paid legal expenses insurance for commercial customers?
Do you currently sell After the Event legal expenses insurance for personal customers?
Do you currently sell After the Event legal expenses insurance for commercial customers?
Please state the other classes of insurance you transact.
Number of years you have been transacting General Insurance
Please advise the number of agencies you have for selling legal expenses insurance.
(excluding CLE)
Please advise the number of agencies you have for selling other classes of insurance.
Do you sell legal expenses insurance through sub agents?
Do you sell other classes of insurance through sub agents?
Have you been, or are you aware of any circumstances which may result in you being, subject to investigation or disiplinary action by a regulatory, trade or professional body?
Have you been, or are aware of any circumstances which may result in you being, refused membership of any professional, trade or regulatory body or had your membership of such a body revoked or suspended?
Have you been, or are you aware of any circumstances which may result in you being, the subject of a bankruptcy petition, an insolvency petition, an application to dissolve, the appointment of a receiver, administrator or trustee or entered into a composition or arrangement with creditors?
Have you been, or are you aware of any circumstances which may result in you being, convicted of an offence other than a driving offence and which is not deemed a spent conviction under the terms of the Rehabilitation Of Offenders Act 1974?
If you have answered Yes to any of the four questions directly above you will be asked to provide full details.
Are you registered under the Data Protection Ac?
Do you have Professional Indemnity Insurance to cover your General Insurance activities?
If yes, please advise
Limit
Excess
   



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