APPLICATION FORM (INDIVIDUAL) MEMBERSHIP LISTING APPLICATION FORM APPLICATION FORM (INDIVIDUAL) MEMBERSHIP LISTING APPLICATION FORM Name of Company* Business Address (Head Office)* Postal Address Telephone Nos*Facsimile Nos*Email Address* Address(es) of Branch Office(s)*Name of Chief Executive Officer* Academic/Professional Qualifications of Chief Executive Officer*Name & Addresses of Partners/Directors of the Company*Please attach copies of Forms C02 and C07* Drop files here or Select files Max. file size: 64 MB. Date of Incorporation* MM slash DD slash YYYY Please Attach copy of Certificate*Max. file size: 64 MB.How long has Company been conducting Business as INSURANCE BROKER?* Give the names of at least three Insurance Companies with whom you have placed insurance business in the last one(1) year*Is your Company indebted to any of the Insurance Companies?* Yes No Please give details of such IndebtednessIs your Company indebted to NCRIB?* Yes No Please give details of such IndebtednessDo you hold a Professional Indemnity Policy?* Yes No If so, who are the Insurers (or lead Insurers)?What is the sum Insured? Anyone Claim Anyone Period Please attach evidence of current coverMax. file size: 64 MB.Have you operated as Insurance Brokers before now under a different name?* Yes No If yes, please give the name and a short brief on why the change of name?Please give details of MANAGEMENT STRUCTURE and SHAREHOLDING of your Company*Please attached Corporate ProfileMax. file size: 64 MB.Declared New Commission in the last three (3) years:YEAR 1* YEAR 2* YEAR 3* DECLARATION* We DECLARE that all the answers and details given above are true and correct. (Any detail found to be incorrect may nullify our application)CHAIRMAN/DIRECTOR* First Last Date* MM slash DD slash YYYY CHIEF EXECUTIVE OFFICER* First Last Date* MM slash DD slash YYYY Name of Company* Business Address (Head Office)* Postal Address Telephone Nos*Facsimile Nos*Email Address* Address(es) of Branch Office(s)*Name of Chief Executive Officer* Academic/Professional Qualifications of Chief Executive Officer*Name & Addresses of Partners/Directors of the Company*Please attach copies of Forms C02 and C07* Drop files here or Select files Max. file size: 64 MB. Date of Incorporation* MM slash DD slash YYYY Please Attach copy of Certificate*Max. file size: 64 MB.How long has Company been conducting Business as INSURANCE BROKER?* Give the names of at least three Insurance Companies with whom you have placed insurance business in the last one(1) year*Is your Company indebted to any of the Insurance Companies?* Yes No Please give details of such IndebtednessIs your Company indebted to NCRIB?* Yes No Please give details of such IndebtednessDo you hold a Professional Indemnity Policy?* Yes No If so, who are the Insurers (or lead Insurers)?What is the sum Insured? Anyone Claim Anyone Period Please attach evidence of current coverMax. file size: 64 MB.Have you operated as Insurance Brokers before now under a different name?* Yes No If yes, please give the name and a short brief on why the change of name?Please give details of MANAGEMENT STRUCTURE and SHAREHOLDING of your Company*Please attached Corporate ProfileMax. file size: 64 MB.Declared New Commission in the last three (3) years:YEAR 1* YEAR 2* YEAR 3* DECLARATION* We DECLARE that all the answers and details given above are true and correct. (Any detail found to be incorrect may nullify our application)CHAIRMAN/DIRECTOR* First Last Date* MM slash DD slash YYYY CHIEF EXECUTIVE OFFICER* First Last Date* MM slash DD slash YYYY