Broker Application

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 referencesPlease 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of private medical insurance (and from whom we may take references) including the date from which such agreement was originally made and the approximate gross written premium placed in the last 12 months.Insurer One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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