Camargue Broker Application Form 2021

Broker
Application Form
Important Notice
1. This application cannot be processed unless all fields and pages are completed in full, and the required supporting documentation is attached.
2. Proof of insurance cover as required must be provided.
3. Proof of banking details not older than 3 months must be provided either as a letter from the bank or a bank statement.
4. Please send the completed application form and supporting documentation to [email protected]
1 | Company Details
Name in full, including current trading title, if any:
Previous trading names, agencies or brokers with whom you have been associated:
Type of Business CHOOSE:

Please Select
Registration no (if applicable) or details if ‘other’
Have any of the directors, shareholders or key individuals of the company, or has any organisation in which they have held a managerial position
been placed in provisional or final liquidation, receivership or been placed under provisional or final judicial management, or been provisionally or
finally sequestrated or entered into arrangements with creditors or are any such matters still pending? If yes, please provide full details.
Have any of these persons been convicted of any criminal offence during the past 5 years? If yes, please provide full details.
Is there any civil or criminal litigation pending against any of the persons mentioned above or against the applicant? If yes, please provide full details.
Have any of these persons ever had any agency or an agency application declined, terminated or granted on special terms?
If yes, please provide full details.
AUTHORISED FINANCIAL SERVICES PROVIDER, LICENCE NUMBER: 6344. APPROVED LLOYD’S COVERHOLDER PIN: 107824DRW
Camargue Underwriting Managers (Pty) Ltd. Co. Reg. No. 2000/028098/07.
33 Glenhove Road, Melrose Estate, 2196. Telephone: 011 778 9140, E-mail: [email protected], Website: www.camargueum.co.za.
UNDERWRITTEN BY THE LICENSED INSURERS:
Certain underwriters at Lloyd’s Bryte Insurance Company Limited Compass Insurance Company Limited
1
A Fairfax Company Co. Reg. No. 1994/003010/06
Co. Reg. No. 1965/006764/06 FSP (12148)
FSP (17703)
Broker
Application Form
2 | Contact Details
Physical address from which business is conducted:
Business tel: Cell:
Fax: Email:
Postal address: Postal code:
Website:
3 | Other Contact Details
Main contact person: Email:
Underwriting contact person: Email:
Claims contact person: Email:
Accounts contact person: Email:
4 | Banking Details
Bank: Branch:
Branch code: Type of account:
Account number: Name of account holder:
5 | Facility/Contract Details
List the names only of any other insurance company and/or underwriting agency with whom you place business
1. 2:
3: 4:
5: 6:
7: 8:
2
Co. Reg. No. 1965/006764/06 FSP (12148)
FSP (17703)
Broker
Application Form
6 | Tax Status
Is the Company a registered taxpayer?
Income tax number: VAT registration number:
7 | Financial Advisory and Intermediary Services Act

Please note that your application cannot be approved if you have not registered correctly in terms of FAIS.
FSP licence number:
Category (e.g. Cat I / II / IIA III / IV):
What type of financial service the FSP is registered to provide:
Please provide sub-category product details e.g. 1.2 (short-term insurance personal lines); 1.6 (short-term insurance commercial lines)
Are there any other conditions applicable for licence categories:
If the answer is Yes, please provide details of such conditions:
Name of registered Compliance Officer:
Cell: Business tel:
Email:
8 | Cover Details
Please attach supplementary proof (i.e. policy schedule or proof of cover)
Professional Indemnity Cover (compulsory for all FSP’s in terms of the Notice on Requirements for Professional Indemnity and Fidelity Insurance
Cover for Providers, published in Board Notice 123 of 2009)
Excess structure: Underwriter:
Limit of indemnity: Policy number:
Expiry date:
9 | Declaration – personal service provider in terms of the income tax act

The Company does not derive more than 80% of its annual income from 1 (one) client only
The Company employs 3 (three) or more full time employees who are not shareholders or members/directors of the Company.
3
Co. Reg. No. 1965/006764/06 FSP (12148)
FSP (17703)
Broker
Application Form
10 | General Declaration
I warrant that the information contained in this application is true and correct.
I understand that Camargue Underwriting Managers may approve or reject this application at its sole discretion.
If this application is successful, Camargue Underwriting Managers’ Intermediary Agreement relating to its business will govern the relationship
between Camargue Underwriting Managers, its Insurers and the Company.
I warrant that all key individuals and representatives of the company are FAIS compliant and accredited.
I warrant that all current, and any subsequent new, key individuals and representatives of the Company will complete the necessary Camargue
Underwriting Managers’ Product Specific Training.
I warrant that I am duly authorised to sign this application on behalf of the Company.
Proposal/declarations completed by
Signature of the Proposer Date DD/MM/YYYY
The acceptance of this proposal is subject to the final approval of Camargue Underwriting Managers.
Camargue Underwriting Managers will not accept responsibility for cover until written confirmation has been issued and the agreement between the
parties has been concluded.
4
Co. Reg. No. 1965/006764/06 FSP (12148)
FSP (17703)

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Broker

2. Proof of insurance cover as required must be provided.

Name in full, including current trading title, if any:

Type of Business CHOOSE:

Registration no (if applicable) or details if ‘other’

Business tel: Cell:

Postal address: Postal code:

3 | Other Contact Details

Main contact person: Email:

Underwriting contact person: Email:

Claims contact person: Email:

Accounts contact person: Email:

Branch code: Type of account:

Account number: Name of account holder:

Income tax number: VAT registration number:

7 | Financial Advisory and Intermediary Services Act

FSP licence number:

Category (e.g. Cat I / II / IIA III / IV):

What type of financial service the FSP is registered to provide:

Are there any other conditions applicable for licence categories:

If the answer is Yes, please provide details of such conditions:

Name of registered Compliance Officer:

Cell: Business tel:

Excess structure: Underwriter:

Limit of indemnity: Policy number:

9 | Declaration – personal service provider in terms of the income tax act

Signature of the Proposer Date DD/MM/YYYY

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