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                        Agency Application Form
This form is required for all new agency applications and must be completed in full. If you already have an agency, 
this form may be requested for additional agency applications. Please discuss this with your local Mutual & Federal 
branch or our Agency Management Division situated in Johannesburg Tel: 011 374 2485. Details of our agencies and 
the businesses linked thereto is treated with the utmost confidentiality.
Section 1
General information
(If the applicant is an individual then sub-sections A,C & D must be completed. If the applicant is a  
Business then sub-sections B, C & D must be completed.)
A. Where the applicant is an individual:
1.  Title:              2. Initials:
3.  First Names:
4. Surname:
5.  ID Type:
  SA Identification:
 ID Number: 
  Other:
 Number:
6.  Date of Birth:
B. Where the applicant is a business:
7.  Name of business:
8.  Company type:    Trust      Sole Proprietor    Partnership
 Private Company       Closed Corporation   Limited Liability Company
9.  Business Registration Number:
      9.1  Total Staff Complement:
 Administration:
 Underwriting:
 Claims:
 Accounts: 
Authorised Financial Services Provider
 Management:  
Authorised Financial Services Provider A member of the  Group
A member of the  GroupC. Address details:
10.  Is the agency registered locally or in a foreign country?  Local:  Foreign:
11.  If foreign then please supply:
 Country:
 Postal Code:
12.  Postal Address: 
 Suburb:
 City/Town:
 Postal Code:
13. Physical Address: 
 
 Suburb:
 City/Town:
 Postal Code:
14. Tel. Office:  Country Code:                Area Code:
                   Number:
15.  Fax:                 Country Code:                        Area Code:
                   Number:
16.  E-mail Address:
17.  Cellphone Number: 
D. Agency details:
18.  Occupation: (e.g. Insurance Broker): 
19.  Number of years in current occupation:
20.  FAIS Number:
21.  F.I.A. Number:
22. Please indicate type of agency:   Direct:    Credit:
23.  Has a guarantee been lodged with the Insurance Association (If credit)?
 Yes:    No: 
24.  If yes, please supply the following:
 24.1 I.G.F Number:
 24.2 Guarantee Amount:  
 24.3 Expiry date: 
        24.4 Do you make use of Premium Collections?    Yes:                        No:
                  Name of collections house if applicable:25. Main contact person at the business?    
 25.1 Title:
 25.2 Name:
 25.3 Surname:
 25.4 Business Title: (e.g. Managing Director)
 25.5 Language Preference:   English:   Afrikaans:
 25.6 Email address:
26. Correspondence section
 26.1 Preferred method of dispatch:             Email:           Post:
 26.2 Underwriting email address (if email):
 26.3 Claims email address:
 26.4 Commission statement email address:
 
Section 2
Tax Details
1.  Tax Region:
2.  Tax Number:      (Attach proof from SARS)
3.  VAT Vendor:     Yes:   No: For office use:
4.  Vat Number: Tax Type:
5.  Tax Directive: Tax Indicator:
   Percentage:                                   %
   Period From:                   To:
6.  Provisional Tax Payer?              Yes:                        No:
     (Attach proof from SARS)
7.  Personal Services Provider?  Yes:                        No:
     (More than 80% income from one source and/or less then 3 non-related employees)
Section 3
Bank Details
1.  Bank Account Type:        Current:                  Transmission:        Savings:
2.  Bank Account Number:
3.  Bank Branch Code:
 If you do not have the branch code please provide the name of your bank and branch:
4.  Account holder’s Name:
 
 
      (Copy cheque or bank confirmation required) Section 4
Volume of business
Business Estimates:
Please indicate the amount of business you envisage writing, by when, allocated according to the business type:
Business type:                              Target date:    Premium amount:
a)  Personal
b)  Commercial / Corporate
c)  Marine
d)  Engineering
e)  Other
f)  What niche type of business would you like to place with Mutual & Federal: 
g)  Estimated start date?
h)  Estimated annual premium?
 
 
Section 5
Other Insurers
Do you represent any other insurers? If so please indicate the approximate percentage of business  
allocated per insurer.
Percentage 
(Premium)
Name of Insurer:                 Appointment Date
 
Total             100%
If you would like your clients to receive marketing material in the form of direct mail campaigns,  
brochures etc, please tick the relevant box.
Yes:     No:
 Section 6
Please provide us with at least two references:
1.  Name:
 Relationship:
 Address:
 Occupation:
 Telephone: Code:       Number:
2.  Name:
 Relationship:
 Address:
 Occupation:
 Telephone: Code:        Number:
 
Section 7
FAIS and General
1.   Have you previously had an agency contract cancelled?
      Yes:          No:
     If yes, please supply full detail:
2.   Individual and Partnerships:
 Name:
 ID Number:
 Qualifications:
 Experience:  Field                                 Years
3.   Company / Closed Corporations (If more members or directors, please add details on a seperate sheet)
 3.1  Name of director or member:
  ID Number:
  Qualifications:
  Experience:  Field                Years
 3.2  Name of director or member:
  ID Number:
  Qualifications:
  Experience:  Field                Years
4.   Compliance Officer:
  Yes:     No:
5.   Do your key individuals meet the FAIS Fit and Proper requirements?     
  Yes:     No:
6.   Does your organisation meet the FAIS Operational requirements?   
  Yes:     No:
7.   Does your organisation comply with the FAIS Financial soundness requirements?8.    Compliance Report: Please give details of your: 
       8.1  Storage of records:
  
 8.2  Date of last FAIS compliance reporting:
       8.3  Recording of advice:
     
 8.4  Recording of handling of complaints:
      
 8.5  Compliance with FICA:
      
 8.6  Have you/any KI/member or director:
              8.6.1  Applied to Mutual & Federal before: Yes:             No:  
 8.6.2  Been declared insolvent, liquidated or sequestrated?   Yes:             No:
 8.6.3  Been found guilty of any criminal or civil offence?         Yes:             No:
           If yes please supply full detail:
I/we, warrant the information provided is true and correct and that Mutual & Federal  
may perform a credit check on the applicant and the directors/members.
This application is signed at:
Signature:      Capacity:
 
Name:        Date:
Company Stamp:    
Herewith a checklist of all the supporting documents 
we would require to process your application:
Proof of Income Tax Number
Proof of VAT Number if applicable
Proof of Bank Account  
(cancelled cheque or letter from bank not older than 12 months)
Copy of Professional Indemnity Schedule                        
                        
                        結尾
                        
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