Partner Application Form | domusIQ MGA (UK) Ltd

Partner form

Tell us about your business.

Share the company, compliance, premium and contact details we need to review a potential partnership with domusIQ MGA (UK) Ltd.

Required fields are marked with *

The form is structured to help onboarding move quickly, with the important regulatory, professional indemnity and contact information in one place.

Company Details

Other Offices and Staff Info

Professional Indemnity Insurance

Premium Profile

Directors Profile

Important Contact Information

1. Company Details

Company name including Trading Names/Styles*

Please enter a company name

Telephone number (Main Office)*

Please enter a valid phone number

Website*

Please enter a valid URL

Address (Main Office)*

Please enter an address

Registered company number*

Please enter a registered company number

Date business established*

Please select a date

Legal status of company*

Please select an option

FCA Firm reference number*

Please enter a valid FCS firm reference number

Directly Authorised or Appointed Representative?*

Please select an option

Main line of business*

Please enter a main line of business

Are you a member of any groups, networks or associations?

How did you hear about us?*

Please enter a response

Are you registered with www.reg.uk.com?*

Please select an option

Please tell us what interests you about partnering with domusIQ MGA (UK)

2. Other Offices and Staff Info

Is registered address the same as the main office?*

Please select an option

Number of staff

Number of offices

Other office locations

3. Professional Indemnity Insurance

Insurer*

Please enter an insurer

Limit of Indemnity*

Please enter a limit of indemnity

Excess*

Please enter an excess

Date of expiry*

Please select a date

Have you submitted any Professional Indemnity Insurance claims in the last 12 months?*

Please select an option

4. Premium Profile

Approximate annual Written Premiums (£)*

Please select an option

Residential Property owners

Commercial Property Owners

Real Estate

Which other providers do you use to place your business with?
E.g. Name of provider, Estimate of GWP (£)

5. Directors Profile

Please complete the details about your company Directors / Principal(s).

Company Directors / Principal(s) details
Please include names, titles, responsibilities and contact details where relevant.

Have you or any Company Directors, Principals, Partners or Managers ever had an Agency terminated or had an application to enter an Agency Agreement/TOBA refused or declined?*

Please select an option

Have you or any of the Company Directors, Principals, Partners or Managers, or any other organisation in which you or they have held a Managerial/Directorship position ever been, or is aware of any circumstances, which may result in being subject to disciplinary proceedings instituted by any professional or regulatory body?*

Please select an option

Have you or any of the Company Directors, Principals, Partners or Managers, or any other organisation in which you or they have held a Managerial/Directorship position ever been involved in liquidation, receivership or bankruptcy, received a County Court judgement, an administration order or entered into an arrangement with creditors or is any matter pending?*

Please select an option

Have you or any of the Company Directors, Principals, Partners or Managers ever been convicted or charged with (but not yet tried for) a criminal offence other than a motoring offence, involving a non-custodial sentence?*

Please select an option

6. Important Contact Information

Please complete the information on these important contacts in your company to help us with onboarding.

Main contact name*

Please enter a main contact name

Main contact position / title*

Please enter a main contact position / title

Main contact telephone number*

Please enter a valid phone number

Main contact email*

Please enter a valid email address.

Accounts contact name*

Please enter an accounts contact name

Accounts contact position / title*

Please enter an accounts contact position / title

Accounts contact telephone number*

Please enter a valid phone number

Accounts contact email*

Please enter a valid email address

Use this email to send account statements*

Please select an option

Manager contact name

Manager contact position / title

Manager contact telephone

Manager contact email

System access requirements

Your application will be securely submitted to domusIQ MGA (UK) for review.

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