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Premier Insurance Brokers Ltd - The Home of Home Insurance

Registration Form

Please enter your details on the form below. To avoid any delays in your registration, please enter as much information as possible:

Your Details:

  • Date of Birth:

Your Company Details:

  • On average, how many Buildings & Contents Leads do you think you will be referring each month? Please enter a number e.g. '12'

  • Please Select - How did you hear about us/find us:

  • Please tick to confirm that you have read our - Terms & Conditions   (Print Terms & Conditions)


Please answer the following questions by ticking the appropriate box. Where a 'Yes' is ticked, please provide full details. NO YES
Disciplinary Proceedings:
1: Has the firm ever been publicly censored, disciplined, suspended or expelled by the FCA, another regulator, a clearing house, an exchange, a professional body, or a government body or agency?
if yes please give details:
2: Is the firm currently the subject of any disciplinary proceeding by any of the bodies referred to in question 1 above or aware that any proceedings are pending?
if yes please give details:
3: Has the firm ever been the subject of any formal investigation under the powers of the Companies Act 2006?
if yes please give details:
4: Has the firm had anything equivalent to 1-3 (above) occur under relevant overseas provisions?
if yes please give details:
Criminal / Civil Proceedings:
1: Is the firm a defendant in any current civil proceedings connected with professional activities in which an allegation of fraud or dishonesty is being made, the subject of any current criminal proceedings, or has been convicted of any criminal offence, either in the UK or overseas?
if yes please give details:
Insolvency / Bankruptcy / Winding Up:
1. Has the firm:
a) been wound up or had a petition presented, or had a meeting called to consider a resolution, for winding it up; or
if yes please give details:
b) in the case of a company, been the subject of an application to dissolve it or to strike it off the Register of Companies; or
if yes please give details:
c) made, or proposed to make, a composition or voluntary arrangement with any one of more of its creditors; or
if yes please give details:
d) had an administrator or trustee in bankruptcy appointed to it or had an application made for such an appointment; or
if yes please give details:
e) had a receiver appointed to it (whether an administrative receiver or a receiver appointed over particular property); or
if yes please give details:
f) had an application for an interim order made against it under section 252 of the Insolvency Act 1986 (or, in Northern Ireland, section 227 of the Insolvency (Northern Ireland) Order 1989); or
if yes please give details:
g) if it is a sole trader, been the subject of an application for a sequestration order or a petition for bankruptcy; or
if yes please give details:
h) ceased trading in circumstances in which any of its creditors did not receive full payment; or
if yes please give details:
i) had anything equivalent to (a) to (h) above occur under relevant overseas law?
if yes please give details:
Financial Information:
1: Is the firm up to date in it's dealings with HM Revenue and Customs?
if no please give details:
Additional Information:
Please provide details of any further information you feel is relevant to the firm's appointment to Premier Insurance Brokers Ltd

The information given in this form will be 'personal data' for the purposes of the Data Protection Act 1998. The personal data may be used by the FCA in the exercise of any of its functions under the Financial Services & Markets Act 2000, and other legislation that applies to the FCA. This could involve disclosing the personal data to other bodies, such as other regulators or law enforcement agencies. It will not however, be disclosed for any other purpose without permission.

I confirm that to the best of my knowledge all the information entered is correct and true.
I authorise Premier Insurance Brokers Ltd to make such enquiries and seek such further information as it thinks appropriate in the course of verifying the information given in this form.
I am aware that Premier Insurance Brokers Ltd may require further information before determining whether the appointment is to be made.

Please enter the answer to the verification sum below: