PJ Hayman - Travel Insurance and Scheme Specialists

Contact Details

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Registration Details and Directors

Date Established:	(under present ownership)
Companies House Registered Number:
Type of Company:
Classification of Status:
Other Classification:
Parent Company:
Ultimate Holding Company:

Please give details of the directors/partners/proprietors of the company:

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Compliance Details

Have you or any director, principal, partner or senior employee:

If you have answered yes to any of the questions above please add notes below:

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Confirmation

Your Details

First Name:
Surname:
Job Title:

Declaration

I/We apply for an agency with P J Hayman & Company Ltd. and declare that the information given above is correct and that nothing has been withheld which might influence the acceptance of this application.

I/We agree that:

A client's account will be maintained for premiums payable to the Company and such premiums are held in trust for the Company.
I/We will advise the Company of any alterations in the above information.

Submit Application

Are any directors or partners engaged in other business?	Yes / No
Are you registered with the FCA?	Yes / No
Registration Number:
Have the FCA raised any queries on your accounts?	Yes / No
Have any company or underwriter ever cancelled your agency or imposed business restrictions or variations that company's standard agency terms?	Yes / No
Are you part of a broker network?	Yes / No
Please specify the name of the broker network:
Are you able to hold client money?	Yes / No

Been involved in liquidation/bankruptcy proceeding (on you/his/their own account, or in the account of any firm or company with which you/he/they were at the time connected as a Director, Principal or Partner) or had any judgement awarded against you/him/them?	Yes / No
Ever traded under another title or titles?	Yes / No
Been dismissed from any office of employment or any representative position?	Yes / No
Currently any involvement in civil litigation either in your/his/their own account or on the account of any firm or company with which you/he/they has/have been connected as a Director, Principal or Partner	Yes / No
Knowledge of any allegations of negligence against you/him/them or any firm or company with which you/he/they has/have been connected as a Director, Principal or Partner during the last ten years	Yes / No
Had any order made against you/him/them under the Companies Act or the Insolvency Acts?	Yes / No
Had any High Court or County Court Judgements made against you/him/them and if so, so any remain unsatisfied?	Yes / No
Been convicted of any criminal offence (excluding driving offences) not treated as a spent conviction under the Rehabilitation of Offenders Act 1974?	Yes / No