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Directly Authorised

Work With Us - Directly Authorised

Application for Directly Authorised Firms

This form is only for firms that are Directly Authorised by the Financial Conduct Authority (FCA) and should be completed by a controller.

If you need any help completing this form please contact our Intermediary Sales Team on 0345 0615 700 Mon-Fri 9am-5pm.

All information supplied on this form will be checked. If we’re missing anything, we’ll contact you to let you know.

Section 1 - Firm Details

I wish to apply for a Paymentshield Agency

Yes No

Firm's Name (as shown on the Financial Services Register) *

FCA Number *

Firms Registered Address *

District

Town *

County *

Postcode *

Telephone Number *

Email Address *

Website Address

http://

Is your Trading Address different from your Firms Registered Address *

Yes No

We will send all correspondence to this address.

Trading Address *

District

Town *

County *

Postcode *

Telephone Number *

Email Address *

If you would like this application to be connected to a club or service provider, please click ‘Yes’ and select your chosen provider *

Yes No

DA Support Service Provider *

Main Contact at the Firm

The main contact is the individual at your firm who Paymentshield should discuss the application with.

Title *

First Name(s) *

Surname *

Job Title *

Telephone Number *

Section 2 - Controller & Seller Information

Controller Information

A controller is the controller, owner, partner or director of the firm as stated on the FCA register.

Controller 1

Title *

First Name(s) *

Surname *

Date of Birth *

Job Title *

Direct Contact Number *

FCA Individual Reference Number *

Email Address *

Will this individual be arranging Non-investment insurance contracts *

Yes No

Add another Controller

Controller 2

Title *

First Name(s) *

Surname *

Date of Birth *

Job Title *

Direct Contact Number *

FCA Individual Reference Number *

Email Address *

Will this individual be arranging Non-investment insurance contracts *

Yes No

Add another Controller

Controller 3

Title *

First Name(s) *

Surname *

Date of Birth *

Job Title *

Direct Contact Number *

FCA Individual Reference Number *

Email Address *

Will this individual be arranging Non-investment insurance contracts *

Yes No

Add another Controller

Controller 4

Title *

First Name(s) *

Surname *

Date of Birth *

Job Title *

Direct Contact Number *

FCA Individual Reference Number *

Email Address *

Will this individual be arranging Non-investment insurance contracts *

Yes No

Sellers of Non-Investment Contracts

If you would like to list additional sellers of non-investment insurance contracts, please click the 'Add a Seller' button below;

Seller 1

Title *

First Name(s) *

Surname *

Date of Birth *

Job Title *

Direct Contact Number *

FCA Individual Reference Number *

Email Address *

Will this individual be arranging Non-investment insurance contracts *

Yes No

Add another Seller

Seller 2

Title *

First Name(s) *

Surname *

Date of Birth *

Job Title *

Direct Contact Number *

FCA Individual Reference Number *

Email Address *

Will this individual be arranging Non-investment insurance contracts *

Yes No

Add another Seller

Seller 3

Title *

First Name(s) *

Surname *

Date of Birth *

Job Title *

Direct Contact Number *

FCA Individual Reference Number *

Email Address *

Will this individual be arranging Non-investment insurance contracts *

Yes No

Add another Seller

Seller 4

Title *

First Name(s) *

Surname *

Date of Birth *

Job Title *

Direct Contact Number *

FCA Individual Reference Number *

Email Address *

Will this individual be arranging Non-investment insurance contracts *

Yes No

Section 3 – Legal Status of the Firm

Legal Status of Firm

Please select the legal status of your firm from the list provided. *

Other, please specify *

Section 4 – Product Information

Product Information

Is General Insurance your firm's primary activity? *

Yes No

How many Paymentshield policies do you anticipate selling each month? *

Are more than 15% of your customers classed as vulnerable as described by the FCA? *

Yes No

Have you or the firm been selling General Insurance for longer than 12 months? *

Yes No

Section 5 – Banking Details

Banking Details

This must match the firm’s name as stated in section one.

Name of Account *

Bank Sort Code *

Bank Account Number *

Section 6 – Commission Details

Commission

When establishing a new Paymentshield agency, your commission method will default to Annualised Indemnity. For a full description of all our commission options, please visit the Earnings page. If you wish to receive your commission payment in a different way, please select your preferred method below:

How would you like to receive your Paymentshield commission? *

Annualised Indemnity Enhanced Indemnity Double Indemnity

Commission statements will automatically be sent to the firm's main contact email address stated in step 1.

If you would like these to be sent to an alternative email address please state here:

Section 7 – Disclosure

Disclosure

Has the firm had a receiver or administrator appointed, failed to satisfy a debt or reached an arrangement with any of its creditors or had a petition for bankruptcy or compulsory winding up of the firm? *

Yes No

Please provide more information *

Has the firm or any of its controllers at any time been convicted of fraud or other dishonesty, or any offence under legislation, or sanctioned by a regulatory body? *

Yes No

Please provide more information *

Are there any other significant events regarding the firm or any companies in the firm’s group that might adversely affect this application? *

Yes No

Please provide more information *

I can confirm that my firm has current Professional Indemnity cover. *

Yes No

Section 8 – Declaration and Data Protection Notification

Declaration and Data Protection Notification

Data Protection Notice

The personal information provided in this form may be 'personal data' as defined in the Data Protection Act 1998 (DPA) and will be used by Paymentsheild Limited. We may obtain further personal data about you or your firm from credit reference agencies, the Financial Conduct Authority (FCA) and/or other regulatory bodies. We will use this information to decide whether to enter into the agreement with the firm and then periodically whether to continue with that agreement. We may use the information to administer our agreement with the firm.

We may share all information we have about you with insurance companies, credit reference agencies, debt recovery agencies, tracing services, the FCA and/or other regulatory bodies in order to protect our and others' interests, and to prevent fraud. We may use information that is not sensitive personal data as defined by the DPA for marketing purposes, and may share this information within the Towergate Group.

When you provide us with this information you are consenting to our use of it as set out in this notice.

If you have questions about our use of personal information, or you believe our records are inaccurate, you should write to the Data Protection Officer, Paymentshield Limited, PO Box 229, Southport, PR9 9WU

I confirm that I have read and understand the above Data Protection Notice *

I confirm

I as stated in the controller section can confirm I am the controller, owner, partner or director of the firm and the information in this form is complete and correct to the best of my knowledge, information and belief, and that there are no relevant facts of which the Paymentshield Group of companies and or alliance partners should be aware of. *

I confirm

I confirm that I have read the Agency Terms & Conditions and I hereby agree on behalf of the firm to be bound and comply with the obligations and requirements contained therein. *

I confirm

If you are requesting your Directly Authorised application to be affiliated to a DA Support Service Provider of Paymentshield, you confirm that you agree to us passing on any of your log in details for you to the affiliated Support Service Provider.

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Call our INTERMEDIARY SALES TEAM on 0345 0615 700
Monday - Friday

9am - 5pm

Call our BROKER SUPPORT TEAM on 0345 0615 100

Monday - Friday 8am - 7pm

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Paymentshield Limited (registered number 02728936) is a company registered in England and Wales at Paymentshield House, Southport Business Park, Wight Moss Way, Southport, PR8 4HQ. Telephone calls may be recorded for security purposes and monitored under our quality control procedures.

Paymentshield Limited is authorised and regulated by the Financial Conduct Authority (FCA) under registration No. 312708.See the Financial Services Register for further details.

© Paymentshield Limited 2019