Lloyd's Broker Registration Form

1
Lloyd’s Broker Registration
Application form
August 2009

Lloyd’s Broker Registration Application Form

Contents

1General Information About Your Firm03

2Lloyd’s information06

3Applicant checkllist08

Annex A: - Additional Requirements for non-EU firms11

Annex B: - Key Individual Details for non-EU firms16

Please read the following notes carefully before completing this form.

Please read the accompanying “Lloyd’s Broker Registration: A Guide for Applicants” before completing this form.
If the form does not provide enough space for your answers, please continue your answers on a separate sheet of paper. Your answers should quote the relevant form part and question.
If you are part of a group of companies, please answer all questions for your particular company and not the group.
Reference to “you”, “your” or “your firm” means the entity that is applying for registration on this form.
You can either:

Fill in this form on screen and then print off a copy for signing; or

Print off a copy of this form and complete it by hand (in English and using BLOCK CAPITALS)

Responses to questions using tick boxes should be indicated by either clicking on the appropriate box, or inserting an “x”.
When all parts of this form have been filled in, please remember to sign and retain a copy of this application before submitting it to Lloyd’s Relationship Management team, 1 Lime Street, London, EC3M 7HA, or to the appropriate Lloyd’s General Representative.
When submitting your application, please ensure that you provide all the necessary documentation indicated in the relevant applicant checklist, namely the UK/EU applicant checklist or the non-EU applicant checklist. Applications which are not complete, or do not include all documents required may be returned to the applicant.

This version form was released in August 2009.
© Lloyd’s.

Lloyd’s Broker Registration Application Form

1General information about your firm

1.1Name of your firm

1.2Trading as / doing business as (if different from above)

1.3Company registration number

1.4Place/country of incorporation

1.5Date of incorporation (format DD/MM/YYYY)

/ / /

1.6The firm is (please place cross in one box only)

Sole proprietor
Partnership
Private company
Public company
Other /

1.7Relevant addressesList all of your firm’s addresses for the past six years. It is important that you include your full postcode

Registered office
Address /
Postcode/zipcode /
Country /
Principal office or postal address (if different)
Address /
Postcode / Zipcode /
Country /

1.8Your firm’s contact details

Telephone /
Fax /
Email /
Website /

1.9Details of person who is co-ordinating this application

Name /
Position / job title /
Telephone /
Fax /
Email /

1.10What is the name of your firm’s external regulatory body?(if applicable)(if applicable):

1.11What is your registration number provided by your external regulatory body? (if applicable)external regulatory body? (if applicable):

1.12Is your firm a member of any insurance industry trade association?

/ Yes / No
If ‘yes’ please provide the following details
Name of trade association /
Registration number / v

1.13Is your firm part of a group of companies?

/ Yes / No
If ‘yes’ please attach a group structure chart showing directors of the ultimate parent company and any shareholdings in the applicant of over 10%, in addition to the following details:
Name of ultimate parent /
Percentage ownership by ultimate parent / %
Number of other companies within the group that operate as insurance brokers, agents or intermediaries /
Address of ultimate parent
Address /
Postcode / Zipcode /
Country /

1.14Please list the main board directors, partners, proprietors or principal officers including finance director, company secretary and any senior employees who will have significant involvement in the handling or administration of Lloyd’s business.

Surname / Forenames / Position / Job title

1.15Other name(s) by which the firm has traded in the last 10 years

2Lloyd’s Information

2.1Has your firm ever applied for, or previously received, approval by Lloyd’s as a broker, umbrella broker, underwriting agent, coverholder or open market correspondent?

/ Yes / No
If yes, please provide the name under which the application
was made /
Date of previous application (format DD/MM/YYYY) / / /
Address of firm at time of previous application
Address /
Postcode / Zipcode /
Country /

2.2Is your firm or any of the individuals identified in question 1.14, associated with an underwriting agent(s) at Lloyd’s?

/ Yes / No

2.3Please provide details of the individuals listed in 1.14 who will be responsible for ensuring that conditions of registration are maintained by the firm:

Name /
Position / Job title
Telephone /
Fax
Email /

2.4Professional indemnity cover (please include currency used) Please provide a copy of the professional indemnity policy with the application and the most recent audited accounts

Amount of professional indemnity cover for each claim /
Amount of professional indemnity cover in aggregate /
Deductible amount for each and every loss /
Deductible amount in the aggregate /
Does the policy cover dishonest acts of directors? / Yes / No
Does the policy cover dishonest acts of employees? / Yes / No
If ‘Yes’ what is the limit? /
If ‘Yes’ what is the deductible? /
If ‘No’ do you have separate fidelity cover? / Yes / No

2.5Have any unusual terms ever been imposed by your professional indemnity insurers?

/ Yes / No

2.6Have there been any professional indemnity claims or circumstances that you are aware of that might have given rise to a claim (whether insured or not) in the last five years?

/ Yes / No

2.7If you have answered yes to 2.6 or 2.7 please provide details:

2.8What is your firms total exposure to the pending claims, if applicable (please include currency used)?Please note: this information will be kept confidential

2.9Has your firm established strictly segregated client money accounts in order to hold Lloyd’s client money separate from other insurance clients’ money and from the firms own operating accounts?

/ Yes / No

2.10Please provide details of how Lloyd’s client money will be held in practice

In a segregated client money trust account: /
In a segregated client money non-trust account: /
In some other account: /

3UK/EU applicants checklist

Applicants must ensure that all documentation listed below is included with their formal submission or the review and approval process will be delayed.
1Completed and signed application form
2Structure chart of the group (up to the ultimate holding company) of which the applicant is part, showing directors/partners of the group and all shareholdings over 10%
3Evidence of membership or authorisation from the relevant regulatory body
4Copies of Professional Indemnity insurance certificate and full policy wording confirming compliance with Lloyd’s requirements
5Confirmation from your bank that Lloyd’s client monies will be held in strictly segregated client money accounts
Formal applications are invited by Lloyd’s once each of the above areas has been addressed. As explained in section 2 of the guide for applicants, there are two further areas where confirmations must be provided before you may become a registered broker at Lloyd’s. Obtaining these confirmations is typically the most time consuming part of the registration process and in view of this, applications are invited while work is still underway in these areas. These are as follows: -
6Letter of support from at least 1 managing agent, confirming that it is willing to enter into a terms of business agreementwith your firm in the event of your successful registration as a Lloyd’s broker (to be signed by a director of that managing agent)
7Confirmation from Xchanging that your firm (or nominated outsource provider) is able to operate the necessary accounting and settlement and claims advice and settlement processes to transact at Lloyd’s and that Xchanging has received all necessary documentation to set up and support such processing (please refer to the separate Xchanging Application Information Pack for more details).

Declaration statement

I confirm and undertake on behalf of the applicant and each of the persons named in section 1.14 of this application form that:

1I am authorised to make this declaration and to provide the information that is contained in this application form and in any supporting documentation;

2The information supplied in and with this application form is complete and accurate to the best of the applicant’s knowledge and belief;

3The applicant understands that the burden is on it to demonstrate to Lloyd’s that it is suitable to be registered as a Lloyd’s broker and that registration as a Lloyd’s broker is always at Lloyd’s discretion;

4If it is granted registration as a Lloyd’s broker, the applicant will comply with Lloyd’s Acts 1871 – 1982 and every byelaw made there under and every requirement, condition, direction or order that is made or imposed under such byelaw that applies to it;

5The applicant will notify Lloyd’s Relationship Management team forthwith of all material changes to the information contained in and with this application form;

6If it is granted registration as a Lloyd’s broker, the applicant will use the Lloyd’s brand in line with Lloyd’s brand guidelines. The applicant understands and agrees that if no business is placed at Lloyd’s within a reasonable timeframe, determined at the discretion of Lloyd’s, it may be removed from the register of Lloyd’s brokers;

7In the event that this application is refused or in the event that the applicant’s name is subsequently removed from the register of Lloyd’s brokers for whatever reason, the applicant shall not seek to challenge the decision prior to exhausting any rights of review or appeal as provided for by the Council of Lloyd’s; and

8We have read the terms of the attached data protection notice and consent to the personal information contained within this form being processed in accordance with these terms.

Signed for and on behalf of the applicant
CEO /
Print name /
Date (DD/MM/YYYY) /

Data protection notice

1Data Controller

1.1Any information relating to your Lloyd’s broker application and registration will be processed within the United Kingdom and so all personal information will be protected by the Data Protection Act 1998 (“the Act”). For the purposes of this Act, Lloyd’s is known as the data controller and holds information for the purposes set out in its notification to the Data Protection Commissioner. You can view this notification at

2Proposed uses of personal information

2.1Lloyd’s will classify information it receives by way of this application and subsequent disclosures as either:

Class A information (which may be business-sensitive or personal information which will only be used by Lloyd’s in line with the terms set out in 2.2 below); or
Class B information (which will be made publicly available as per paragraph 3 below).
Class A information supplied to Lloyd’s by the applicant will be used and/or made available to the following:
The Society including its representatives and agents. This will include Lloyd’s general representatives, attorneys-in-fact and Lloyd’s agents.
Interested third parties such as Xchanging Ins-sure Services, Xchanging Claims Services, Lloyd’s managing agents, the Financial Services Authority and the Lloyd’s Market Association (among others).
Lloyd’s can use class A information for the purposes of processing the application and for monitoring the applicant’s role as a Lloyd’s broker.
Lloyd’s may check all the information it receives about the applicant against information held in Lloyd’s records. In order to check the information, Lloyd’s may need to contact the applicant or, if relevant, any of the parties listed in 2.2.

3Register of Brokers

3.1Lloyd’s will maintain a public register of Class B non-sensitive business information on Lloyd’s Brokers. This register will give the name, address and contact details of the Lloyd’s Broker and details of the jurisdiction in which the Lloyd’s Broker is domiciled. This public register will be available on

4Security and confidentiality of information

4.1All information obtained from the applicant provided in the application form, and any information about the applicant as a result of this or any other application the applicant has made to, or any other agreement the applicant may have with, Lloyd’s, will be securely held by Lloyd’s and its agents on paper or on computer (or both).

4.2Lloyd’s will treat personal information as confidential (even if the applicant ceases to be a Lloyd’s Broker). However, the information that appears on the Lloyd’s Broker Register will be publicly available (as explained at paragraph 3).

4.3Personal information may be transferred to individuals or organisations outside the EEA in countries which may not provide legal protection of information which is equivalent to the protection provided in the United Kingdom. Details of the individuals, organisations and countries involved will be provided on request.

5Disclosure

5.1Except as previously explained, nothing about this application will be disclosed to anyone other than those listed in paragraph 2 unless:

the requirements of the Council, including the Miscellaneous Provisions Byelaw (No.4 of 2006) permits such disclosure; or
the applicant requests, or consents to, Lloyd’s disclosing the information.

6Access to information

6.1Applicants and their directors, partners and proprietors have the right of access to the personal data Lloyd’s and its agents hold about them. They also have the right to prevent it from being used for direct marketing purposes.

6.2Enquiries relating to the use of personal data should be addressed to:

Data Protection Officer
Lloyd’s
One Lime Street
London
EC3M 7HA
United Kingdom

ANNEX A: ADDITIONAL REQUIREMENTS FOR NON-EU FIRMS
(To be completed and submitted with the Lloyd’s Broker Registration Application Form by non-EU applicants)

1General information about your firm

1.16Primary activity of the firm

1.17Does the firm conduct any business other than insurance?

/ Yes / No
If yes please provide details

1.18Approximate number of employees in the firm

1.19Please list the names of all insurers with whom you have an agency agreement or appointment which represents more than 10% of your agency business

1.20In some countries the firm or individuals within the firm are required by law or regulation to be licensed to conduct insurance broking activities or to act as an insurance agent. Please describe any licences required by local law or regulation held by the firm and its principal staff

1.21Has your firm, or any of its current directors, partners, proprietors, principal officers or key senior members of staff ever been convicted of any offence involving dishonesty, including theft, robbery, burglary, handling stolen property, forgery, fraud, income tax evasion or any other offence which may affect underwriters’ judgement as to whether they wish to accept business from your firm?

/ Yes / No

1.22Has your firm or any of its current directors, partners, proprietors, principal officers or key senior members of staff ever been the subject of a voluntary arrangement with creditors or any insolvency proceedings (e.g. administration, liquidation or bankruptcy)?

/ Yes / No

1.23Has your firm, or any of its current employees, partners or directors ever had its/his/her business licence (s) suspended or revoked or re-licensing refused?

/ Yes / No

1.24Has your firm’s membership of any association ever been declined, cancelled or withdrawn?

/ Yes / No

1.25Has your firm, or any of its directors, partners, proprietors, principal officers or key senior members of staff been censured, fined or had conditions imposed by any externalinsurance regulator?

/ Yes / No

1.26If you have answered yes to any of the questions above please provide details

2Lloyd’s information

2.12Do you currently transact business with Lloyd’s through a registeredLloyd’s broker(s)?

/ Yes / No
If yes, please provide the name of the broker(s): /

2.13Does your firm intend to handle any of the following types of business (please all that apply)?

Retail
Wholesale
Reinsurance
Outwards reinsurance
Binding authorities

3Summary financial informationPlease include currency used where applicable and ensure that the latest set of audited accounts have been included with this application form

3.1Financial year end (format DD/MM/YYYY)

/ / /

3.2Date of last audited financial statements (format DD/MM/YYYY)

/ / /

3.3Name of auditor

/
Address of auditor
Address /
Postcode / Zipcode /
Country /

3.4Are your auditors qualified to conduct financial audits in accordance with local requirements?

/ Yes / No

3.5Name of regulatory body auditors are registered with

3.6Please state your profit/loss for the last year of audited accounts

3.7Please state the profit/loss projected for the current year of account for which audited accounts are not yet available(it may assist your answer to submit a summary of your budget for the current year)

3.8Please state amount of paid up (paid in) share capital (please show currency used)

3.9Please state the value of intangible assets, such as goodwill (please show currency used)

3.10Are two signatories required on payments drawn on any insurance accounts?

/ Yes / No

3.11As per the firms last audited financial statements please show the following information

Insurance debtors due within 3 months /
Insurance debtors due within 4-12 months /
Insurance debtors due later than 1 year /
Total insurance debtors /
Total insurance creditors /
Provision for bad debts /

3.12What provision for bad debts has been made since the last audited financial statements?

3.13Are these accounts subject to any charge or lien?If yes, please provide details in 3.15 below

/ Yes / No

3.14Is your firm dependent on a guarantee to support its solvency?If yes, please provide details in 3.15 below

/ Yes / No

3.15If there have been any developments subsequent to your latest financial statements supplied that could materially affect the financial condition of you firm beneficially or adversely, please explain below

4NON EU applicants checklist

Applicants must ensure that all documentation listed below is included with their formal submission or the review and approval process will be delayed.
1Completed and signed application form, including a copy of Annex B completed for every individual listed in 1.14
2Structure chart of the group (up to the ultimate holding company) of which the applicant is part, showing directors/partners of the group and all shareholdings over 10%
3Structure chart of the applicant showing directors/partners and shareholders (over 10%)
42 years of audited financial statements
5Evidence of membership or authorisation from the relevant regulatory body
6Copies of Professional Indemnity insurance certificate and full policy wording confirming compliance with Lloyd’s requirements
7Confirmation from your bank that Lloyd’s client monies will be held in strictly segregated client money accounts
Formal applications are invited by Lloyd’s once each of the above areas has been addressed. As explained in section 2 of the guide for applicants, there are two further areas where confirmations must be provided before you may become a registered broker at Lloyd’s. Obtaining these confirmations is typically the most time consuming part of the registration process and in view of this, applications are invited while work is still underway in these areas. These are as follows: -
8Letter of support from at least 1 managing agent, confirming that it is willing to enter into a terms of business agreement with your firm in the event of your successful registration as a Lloyd’s broker (to be signed by a director of that managing agent)
9Confirmation from Xchanging that your firm (or nominated outsource provider) is able to operate the necessary accounting and settlement and claims advice and settlement processes to transact at Lloyd’s and that Xchanging has received all necessary documentation to set up and support such processing (please refer to the separate Xchanging Application Information Pack for more details)

ANNEX B: KEY INDIVIDUAL DETAILS FOR NON-EU FIRMS
(To be completed and submitted with the Lloyd’s Broker Registration Application Form by non-EU applicants)