Application for Agency Facilities


Date (mm/dd/yyyy):
1. Agent's Trading Name and Address
Name:
Address:
Telephone: ()
Fax: ()
Email Address:
2. Occupation/Nature of Business

3. Are You
a) a registered insurance broker? Yes     No
If Yes, please ignore sections 5,8,9 and 10

-Organization(s)/Network currently registered with:
-Date of registration: (mm/dd/yyyy)
-Registration No.:

b) a member of, or registered with, any official insurance institution?
Yes     No
If Yes, please name institution
4. How Many
years have you been established?
employees, including working directors?
selling individuals are in the organization?
5. Have you been in business for less than two years?
Yes    No If Yes, can you please state the following
Name of previous employer:
Duration of employment:
Contact individual:
Address:
Telephone:() Fax    ()
6. Do you have professional indemnity cover?
Yes No If yes, please send a copy of your certificate, which should state
a) With whom b) Policy number
c) Limit of indemnity d) Excess level (if any)
7. The annual premium income for your international medical insurance portfolio is in the range

a) 0 - $50K
f) Individual %
b) $50K - $100K g) Group %
c) $100K - $250K
d) $250K - $500K
e) $500K +

How would you describe your attitude to international healthcare?
8. Please give
(This section need not be completed if you are a registered broker)
The name and address of three other companies with which you have agency facilities, the date from which they have operated and your approximate premium income with each of them

Name
Address
Date (mm/dd/yyyy) Premium Income

Name
Address
Date (mm/dd/yyyy) Premium Income

Name
Address
Date (mm/dd/yyyy) Premium Income
9. Have agency or collection facilities ever been refused or withdrawn?
Yes     No
If yes, by whom and for what reason?
10. Bank Details
(This section need not be filled in if you are a registered broker)
Name
Address
Telephone() Fax    ()
Goodhealth will cover the cost of any bank fee up to $25.00