Intermediary Application ukeeausc • The Unisure Group

UK/EEA/US AND CANADA

Please refer to the Data Protection Policy for details of how Unisure collects, holds and processes Personal Data.

Step 1 of 11

INTERMEDIARY PROFILE

proceedings sell Correspondence

Full registered name of Intermediary *

Trading name if different

Was the entity ever registered under a different name?

Type of corporation (e.g. Limited Company, LLP, Sole Trader, etc) *

Date incorporated *

Registration Number *

Place of incorporation *

Website of corporation registering authority (e.g. Companies House, EBRA, etc) *

OUR OFFERING

Umatter – International Private Medical Insurance

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Unisure Limited is a Unisure Group company. Unisure Limited is registered in England and Wales with company registration number 9111373, and is authorised and regulated by the United Kingdom Financial Conduct Authority, with FRN 719400.

UK/EEA/US AND CANADA

INTERMEDIARY PROFILE

Address

Intermediary Principal Contact 1

Intermediary Principal Contact 2

Intermediary Administration Contact

Full name of each Director (or equivalent)

Full name of each Shareholder / Beneficial Owner representing at least 10% of voting equity (please ensure that each Ultimate Beneficial Owner is identified):

REGULATORY AUTHORITY DETAILS

PROFESSIONAL INDEMNITY COVER

DOCUMENTS TO BE UPLOADED

DECLARATION

OUR OFFERING

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