Short Form Questionnaire May 2015 Legal Name Principal contact (overall program control) Title Telephone Email Website Underwriting Authority (Please Select) Company Information Reputation and Standing Classes of Business Life A&H Life Personal Accident Other (describe) Commercial Lines Bonds – Surety Business Owners Policy Commercial Auto Commercial Property Cyber Liability Drone Liability General Liability Inland Marine Jewellers’ Block Long Hull Trucking Livestock / Bloodstock Medical Malpractice Ocean Marine Political Risk Professional Liability Renewable Energy Terrorism Other (describe) Core Business Activities Please describe your core business activities, including any non-insurance activities: Pre-determined Rates Prior Submit Business Strategy Please confirm you will provide a business plan to become a Lloyd’s coverholder Have you ever: been charged with or convicted of a criminal offence been a party to any legal action had a licence refused, suspended, withdrawn Financials Please confirm your financials for the last two accounting periods are available Systems Do you have systems to allow you to record underwriting detail, premium and taxes? Licences Please confirm that you will only transact surplus lines business in states where you or another broker in the chain hold the appropriate licence Previous Applications Have you ever had a Coverholder application turned down by Lloyd’s? Yes Yes No No Personal Lines Auto standard Auto non-standard Homeowners Recreational Vehicles Other (describe) Full Lloyd’s Coverholder application will be required Iris Insurance Brokers Ltd is registered in England and Wales (No. 4072404). Registered office: The Baxter Building, 80 Baxter Avenue, Southend-on-Sea, Essex, SS2 6HZ. Iris Insurance Brokers Ltd is authorised and regulated by the Financial Conduct Authority (FCA No. 310825).
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Short Form Questionnaire
May 2015
Legal Name
Principal contact (overall program control)
Title
Telephone
Website
Underwriting Authority (Please Select)
Company Information Reputation and Standing
Classes of Business
Life A&H
Life
Personal Accident
Other (describe)
Commercial Lines
Bonds – Surety
Business Owners Policy
Commercial Auto
Commercial Property
Cyber Liability
Drone Liability
General Liability
Inland Marine
Jewellers’ Block
Long Hull Trucking
Livestock / Bloodstock
Medical Malpractice
Ocean Marine
Political Risk
Professional Liability
Renewable Energy
Terrorism
Other (describe)
Core Business ActivitiesPlease describe your core business activities, including any non-insurance activities:
Pre-determined Rates Prior Submit
Business StrategyPlease confirm you will provide a business plan to become a Lloyd’s coverholder
Have you ever:been charged with or convicted of a criminal offence
been a party to any legal action
had a licence refused, suspended, withdrawn
FinancialsPlease confirm your financials for the last two accounting periods are available
SystemsDo you have systems to allow you to record underwriting detail, premium and taxes?
LicencesPlease confirm that you will only transact surplus lines business in states where you or another broker in the chain hold the appropriate licence
Previous ApplicationsHave you ever had a Coverholder application turned down by Lloyd’s?
Yes
Yes
No
No
Personal Lines
Auto standard
Auto non-standard
Homeowners
Recreational Vehicles
Other (describe)
Full Lloyd’s Coverholder application will be required
Iris Insurance Brokers Ltd is registered in England and Wales (No. 4072404). Registered office: The Baxter Building, 80 Baxter Avenue, Southend-on-Sea, Essex, SS2 6HZ. Iris Insurance Brokers Ltd is authorised and regulated by the Financial Conduct Authority (FCA No. 310825).
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