Register

2. Broker Details

3. Directors or Principals

1	Has the business or any of its directors or principals, In the last 12 months, been convicted of any offence involving fraud, theft, false accounting or other dishonesty? Or been convicted of any offence (whether in the United Kingdom or not) relating to companies, building societies, industrial and provident societies, credit unions, friendly societies, insurance, banking or other financial services, insolvency, consumer credit or consumer protection, money laundering, market manipulations or insider dealing?	Yes No
	Please provide more information
2	Has the business or any of its directors or principals been the subject of any current criminal proceedings?	Yes No
	Please provide more information
3	Has the business or any of its directors or principals had any convictions for any offences other than those listed above whether in the United Kingdom or not (excluding traffic offences unless these resulted in a ban from driving or involved driving without insurance)	Yes No
	Please provide more information
4	Has the business or any of its directors or principals, in the last 12 months, been the subject of any civil proceedings, arbitration or litigation, including proceedings that may lead to a County Court Judgement (CCJ) or other judgement debts, in the United Kingdom or elsewhere?	Yes No
	Please provide more information
5	Is the business or any of its directors or principals aware of any intention to begin such proceedings against the business or Directors or principals?	Yes No
	Please provide more information
6	Since January 2001, has the business or any of the directors or principals failed to satisfy any judgement debts (including CCJ’s) within one year of making the order?	Yes No
	Please provide more information
7	Has the business or any of its directors or principals have any judgement debts (including CCJ’s) made under a court order still outstanding, whether in full or in part?	Yes No
	Please provide more information
8	Has the business or any of its directors or principals, in the last 12 months, been the subject of any bankruptcy proceedings or action for the sequestration of assets?	Yes No
	Please provide more information
9	Has the business or any of its directors or principals in the last 12 months entered into a deed of arrangement or an individual voluntary arrangement (or in Scotland a trust deed) or other agreement in favour of your creditors, or are you doing so?	Yes No
	Please provide more information
10	Has the business or any of its directors or principals, in the last 12 months, been found guilty of conducting any unauthorised regulated activities or been investigated for possible conduct of unauthorised activities?	Yes No
	Please provide more information
11	Has the business or any of its directors or principals, in the last 12 months, been the subject of an investigation into allegations of misconduct/malpractice in connection with any business activity?	Yes No
	Please provide more information
12	Has the business or any of its directors or principals in the last 12 months either in the United Kingdom or elsewhere, been refused entry to, or been dismissed or requested to resign from, any profession, vocation, office or employment or from any fiduciary office or position of trust, whether remunerated or not?	Yes No
	Please provide more information
13	Has the business or any of its directors or principals in the last 12 months, been refused, restricted in, or had suspended, the right to carry on any trade, business or profession for which specific license, authorisation, registration, membership or other permission is required?	Yes No
	Please provide more information
14	Has the business or any of its directors or principals in the last 12 months, either in the United Kingdom or elsewhere, been disqualified by a court from acting as a director of a company or from acting in a management capacity or conducting the affairs of any company, partnership or unincorporated association?	Yes No
	Please provide more information
15	Has the business or any of its directors or principals, in the last 12 months, either in the United Kingdom or elsewhere, been the subject of a disqualification direction under section 59 of the Financial services ACT 1986 or a prohibition order, under sections 56 of the Financial Services and Markets Act 2000, or received a warning notice to make such a direction or order?	Yes No
	Please provide more information
16	In respect of activities regulated by the FCA or any other regulatory body please confirm for all Directors or Principals whether you or any other company, partnership or unincorporated association of which you are, or have been, a controller, director, senior manager, partner or company secretary, during your association with that entity and for a period of three years after the individual ceased to be associated with it ever:	Yes No
	Please provide more information
16a	Been refused, had revoked, restricted or terminated any license authorisation, registration, notification, membership or other permission granted by any such body?	Yes No
	Please provide more information
16b	Been criticised, censured, disciplined, suspended, expelled, fined or been the subject of any other disciplinary or intervention action by any such body?	Yes No
	Please provide more information
16c	Resigned whilst under investigation by, or been required to resign from any such body?	Yes No
	Please provide more information
16d	Decided, after making an application for any license, authorisation, registration, notification, membership or other permission, granted by any such body, not to proceed with it?	Yes No
	Please provide more information
16e	Been the subject of any civil action, which has resulted in a finding against either you as an individual or it by a court?	Yes No
	Please provide more information
17	Are you aware of any business interest, employment obligations, or any other situations that may conflict with the performance of this application?	Yes No
	Please provide more information

4. Declaration

I/We declare that all the information given in this application form is, to the best of my/our knowledge, true and complete. I/we agree that the completed form and any additional information I/we provide will be the basis of the agreement between me/us and My Policy Ltd trading as Measured Miles should it be granted.

I confirm that I am authorised to complete and submit this Agency Application form on behalf of my company.