Lloyd’s
Broker
Registration
Application form
April 2013
2
Contents
1
General Information About Your Firm
03
2
Lloyd’s information
06
3
Applicant checkllist
08
Annex A: - Additional Requirements for non-EU firms
11
Annex B: - Key Individual Details for non-EU firms
16
PLEASE READ THE FOLLOWING NOTES CAREFULLY BEFORE COMPLETING THIS FORM.

Please read the accompanying “Lloyd’s Broker Registration: A Guide for Applicants” before completing this
form.

If the form does not provide enough space for your answers, please continue your answers on a separate sheet
of paper. Your answers should quote the relevant form part and question.

If you are part of a group of companies, please answer all questions for your particular company and not the
group.

Reference to “you”, “your” or “your firm” means the entity that is applying for registration on this form.

You can either:
Fill in this form on screen and then print off a copy for signing; or
Print off a copy of this form and complete it by hand (in English and using BLOCK CAPITALS)

Responses to questions using tick boxes should be indicated by either clicking on the appropriate box, or
inserting an “x”.

When all parts of this form have been filled in, please remember to sign and retain a copy of this application
before submitting it to Lloyd’s Relationship Management team, 1 Lime Street, London, EC3M 7HA, or to the
appropriate Lloyd’s General Representative.

When submitting your application, please ensure that you provide all the necessary documentation indicated in
the relevant applicant checklist, namely the UK/EU applicant checklist or the non-EU applicant checklist.
Applications which are not complete, or do not include all documents required may be returned to the applicant.
This version form was released in April 2013.
© Lloyd’s.
Lloyd’s Broker Registration Application Form
Copyright © Lloyd's 2013
3
1 General information about your firm
1.1 Name of your firm
1.2 Trading as / doing business as (if different from above)
1.3 Company registration number
1.4 Place/country of incorporation
1.5 Date of incorporation (format DD/MM/YYYY)
1.6 The firm is (please select one box only)
Sole proprietor
☐
Partnership
☐
Private company
☐
Public company
☐
Other
1.7 Relevant addresses
List all of your firm’s addresses for the past six years. It is important that you include your full postcode
Registered office
Address
Postcode/Zipcode
Country
Principal office or postal address (if different)
Address
Postcode / Zipcode
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Country
1.8 Your firm’s contact details
Telephone
Fax
Email
Website
1.9 Details of person who is co-ordinating this application
Name
Position / job title
Telephone
Fax
Email
1.10 What is the name of your firm’s external regulatory body?
(if applicable)
(if applicable):
1.11 What is your registration number provided by
your external regulatory body? (if applicable)
external regulatory body? (if applicable):
1.12 Is your firm a member of any insurance industry trade association?
Yes ☐
No ☐
Yes ☐
No ☐
If ‘yes’ please provide the following details
Name of trade association
Registration number
1.13 Is your firm part of a group of companies?
If ‘yes’ please attach a group structure chart showing directors of the ultimate parent company and any
shareholdings in the applicant of over 10%, in addition to the following details:
Name of ultimate parent
Percentage ownership by ultimate parent
%
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Number of other companies within the group that operate as
insurance brokers, agents or intermediaries
Address of ultimate parent
Address
Postcode / Zipcode
Country
1.14 Please list the main board directors, partners, proprietors or principal officers including finance director,
company secretary and any senior employees who will have significant involvement in the handling or
administration of Lloyd’s business. Please attach a CV or résumé for each listed individual. Also, where an
individual has worked within the Lloyd’s market and has been known by another name please provide details.
Surname
Forenames
Position / Job title
Date of birth
1.15 Other name(s) by which the firm has traded in the
last 10 years
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2 Lloyd’s Information
2.1 Has your firm ever applied for, or previously received, approval by Lloyd’s as
a broker, umbrella broker, underwriting agent, coverholder or open market
correspondent?
Yes ☐
No ☐
Yes ☐
No ☐
Yes ☐
No ☐
If yes, please provide the name under which the application
was made
Date of previous application (format DD/MM/YYYY)
Address of firm at time of previous application
Address
Postcode / Zipcode
Country
2.2 Is your firm or any of the individuals identified in question 1.14, associated
with an underwriting agent(s) at Lloyd’s?
2.3 Does your firm operate as a non-Lloyd’s broker, i.e. has a Terms of Business
Agreement (ToBA) in place with a Lloyd’s managing agent?
If ‘yes’ please provide details of the managing agent(s) involved below
_________________________________________________________________
_________________________________________________________________
2.4 Please provide details of the individuals listed in 1.14 who will be responsible for ensuring that conditions of
registration are maintained by the firm:
Name
Position / Job title
Telephone
Fax
Email
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2.5 Professional indemnity cover (please include currency used)
Please provide a copy of the full professional indemnity policy with the application and the most recent audited
accounts.
Amount of professional indemnity cover for each claim
Amount of professional indemnity cover in aggregate
Deductible amount for each and every loss
Deductible amount in the aggregate
Does the policy cover dishonest acts of directors?
Does the policy cover dishonest acts of employees?
Yes ☐
No ☐
Yes ☐
No ☐
Yes ☐
No ☐
Yes ☐
No ☐
Yes ☐
No ☐
Yes ☐
No ☐
If ‘Yes’ what is the limit?
If ‘Yes’ what is the deductible?
If ‘No’ do you have separate fidelity cover?
2.6 Have any unusual terms ever been imposed by your professional
indemnity insurers?
2.7 Have there been any professional indemnity claims or circumstances that
you are aware of that might have given rise to a claim (whether insured or
not) in the last five years?
2.8 If you have answered yes to 2.5 or 2.6 please provide details:
2.9 What is your firms total exposure to the pending claims,
if applicable (please include currency used)?
Please note: this information will be kept confidential
2.10 Has your firm established strictly segregated client money accounts in order
to hold Lloyd’s client money separate from other insurance clients’ money
and from the firm’s own operating accounts?
2.11 Please provide details of how Lloyd’s client money will be held in practice
In a segregated client money trust account:
In a segregated client money non-trust account:
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In some other account:
2.12 Do you intend to place any binding authority business during the first 12
months of registration?
Yes ☐
No ☐
Please note that if the answer to this question is ‘No’ you will not be able to start
broking this type of business in the Lloyd’s market without first receiving sign off from
Xchanging and Lloyd’s Delegated Authorities Team. (This may require you to
complete additional training.)
Lloyd’s Broker Registration Application Form
Copyright © Lloyd's 2013
9
3 UK/EU applicants checklist
Applicants must ensure that all documentation listed below is included with their formal submission or the
review and approval process will be delayed.
1
Completed and signed application form
☐
2
Structure chart of the group (up to the ultimate holding company) of which the applicant
is part, showing directors/partners of the group and all shareholdings over 10%
☐
3
Evidence of membership or authorisation from the relevant regulatory body
☐
4
Copies of Professional Indemnity insurance certificate and full policy wording confirming
compliance with Lloyd’s requirements
☐
5
Confirmation from your bank that Lloyd’s client monies will be held in strictly segregated
client money accounts
☐
6
2 years of audited financial statements
☐
7
Business rationale for becoming a Lloyd’s broker which should include details of the
type of business you will bring to the market and how you intend to operate.
☐
8
Completed Forecast Premium Template
☐
Formal applications are invited by Lloyd’s once each of the above areas has been addressed. As explained in
section 2 of the guide for applicants, there are three further areas where confirmations must be provided
before you may become a registered broker at Lloyd’s. Obtaining these confirmations is typically the most
time consuming part of the registration process and in view of this, applications are invited while work is still
underway in these areas. These are as follows: -
9
10
11
Letter of support from at least 3 managing agents, confirming that they are willing to
enter into a terms of business agreement with your firm in the event of your successful
registration as a Lloyd’s broker (to be signed by a director of the managing agent)
Confirmation from Xchanging that your firm (or nominated outsource provider) is able to
operate the necessary accounting and settlement and claims advice and settlement
processes to transact at Lloyd’s and that Xchanging has received all necessary
documentation to set up and support such processing (please refer to the separate
Xchanging Application Information Pack for more details).
If you intend to place binding authority business in the Lloyd’s market, confirmation from
Xchanging and Lloyd’s Delegated Authorities Team that you have the necessary
procedures and personnel to place and administer this type of business effectively.
☐
☐
☐
Lloyd’s Broker Registration Application Form
Copyright © Lloyd's 2013
10
DECLARATION STATEMENT
I confirm and undertake on behalf of the applicant and each of the persons named in section 1.14 of this
application form that:
1 I am authorised to make this declaration and to provide the information that is contained in this application form and
in any supporting documentation;
2 The information supplied in and with this application form is complete and accurate to the best of the applicant’s
knowledge and belief;
3 The applicant understands that the burden is on it to demonstrate to Lloyd’s that it is suitable to be registered as a
Lloyd’s broker and that registration as a Lloyd’s broker is always at Lloyd’s discretion;
4 If it is granted registration as a Lloyd’s broker, the applicant will comply with Lloyd’s Acts 1871 – 1982 and every
byelaw made there under and every requirement, condition, direction or order that is made or imposed under such
byelaw that applies to it;
5 The applicant will notify Lloyd’s Relationship Management team forthwith of all material changes to the information
contained in and with this application form;
6 If it is granted registration as a Lloyd’s broker, the applicant will use the Lloyd’s brand in line with Lloyd’s brand
guidelines. The applicant understands and agrees that if no business is placed at Lloyd’s within a reasonable
timeframe, determined at the discretion of Lloyd’s, it may be removed from the register of Lloyd’s brokers;
7 In the event that this application is refused or in the event that the applicant’s name is subsequently removed from
the register of Lloyd’s brokers for whatever reason, the applicant shall not seek to challenge the decision prior to
exhausting any rights of review or appeal as provided for by the Council of Lloyd’s; and
8 We have read the terms of the attached data protection notice and consent to the personal information contained
within this form being processed in accordance with these terms.
Signed for and on behalf of the applicant
CEO
Print name
Date (DD/MM/YYYY)
Lloyd’s Broker Registration Application Form
Copyright © Lloyd's 2013
11
DATA PROTECTION NOTICE
1
Data Controller
1.1 Any information relating to your Lloyd’s broker application and registration will be processed within the United Kingdom and so all
personal information will be protected by the Data Protection Act 1998 (“the Act”). For the purposes of this Act, Lloyd’s is known as
the data controller and holds information for the purposes set out in its notification to the Data Protection Commissioner. You can
view this notification at http://www.ico.gov.uk/tools_and_resources/register_of_datacontrollers.aspx.
2
Proposed uses of personal information
2.1 Lloyd’s will classify information it receives by way of this application and subsequent disclosures as either:

Class A information (which may be business-sensitive or personal information which will only be used by Lloyd’s in line with
the terms set out in 2.2 below); or

Class B information (which will be made publicly available as per paragraph 3 below).
2.2 Class A information supplied to Lloyd’s by the applicant will be used and/or made available to the following:

The Society including its representatives and agents. This will include Lloyd’s general representatives, attorneys-in-fact and
Lloyd’s Agents.

Interested third parties such as Xchanging Ins-sure Services, Xchanging Claims Services, Lloyd’s managing agents, the
Financial Services Authority and the Lloyd’s Market Association (among others).
2.3 Lloyd’s can use class A information for the purposes of processing the application and for monitoring the applicant’s role as a
Lloyd’s broker.
2.4 Lloyd’s may check all the information it receives about the applicant against information held in Lloyd’s records. In order to check
the information, Lloyd’s may need to contact the applicant or, if relevant, any of the parties listed in 2.2.
3
Register of Brokers
3.1 Lloyd’s will maintain a public register of Class B non-sensitive business information on Lloyd’s Brokers. This register will give the
name, address and contact details of the Lloyd’s Broker and details of the jurisdiction in which the Lloyd’s Broker is domiciled. This
public register will be available on www.lloyds.com
4
Security and confidentiality of information
4.1 All information obtained from the applicant provided in the application form, and any information about the applicant as a result of
this or any other application the applicant has made to, or any other agreement the applicant may have with, Lloyd’s, will be
securely held by Lloyd’s and its agents on paper or on computer (or both).
4.2 Lloyd’s will treat personal information as confidential (even if the applicant ceases to be a Lloyd’s Broker). However, the
information that appears on the Lloyd’s Broker Register will be publicly available (as explained at paragraph 3).
4.3 Personal information may be transferred to individuals or organisations outside the EEA in countries which may not provide legal
protection of information which is equivalent to the protection provided in the United Kingdom. Details of the individuals,
organisations and countries involved will be provided on request.
5
Disclosure
5.1 Except as previously explained, nothing about this application will be disclosed to anyone other than those listed in paragraph 2
unless:
6

the requirements of the Council, including the Miscellaneous Provisions Byelaw (No.4 of 2006) permits such disclosure; or

the applicant requests, or consents to, Lloyd’s disclosing the information.
Access to information
6.1 Applicants and their directors, partners and proprietors have the right of access to the personal data Lloyd’s and its agents hold
about them. They also have the right to prevent it from being used for direct marketing purposes.
6.2 Enquiries relating to the use of personal data should be addressed to:
Data Protection Officer
Lloyd’s
One Lime Street
London
EC3M 7HA
United Kingdom
Lloyd’s Broker Registration Application Form
Copyright © Lloyd's 2013
12
ANNEX A: ADDITIONAL REQUIREMENTS FOR NON-EU FIRMS
(To be completed and submitted with the Lloyd’s Broker Registration Application Form by non-EU applicants)
1 General information about your firm
1.16 Primary activity of the firm
1.17 Does the firm conduct any business other than insurance?
Yes ☐
No ☐
If yes please provide details
1.18 Approximate number of employees in the firm
1.19 Please list the names of all insurers with whom you have an agency agreement or appointment which
represents more than 10% of your agency business
1.20 In some countries the firm or individuals within the firm are required by law or regulation to be licensed to
conduct insurance broking activities or to act as an insurance agent. Please describe any licences required by
local law or regulation held by the firm and its principal staff
1.21 Has your firm, or any of its current directors, partners, proprietors, principal
officers or key senior members of staff ever been convicted of any offence
involving dishonesty, including theft, robbery, burglary, handling stolen
property, forgery, fraud, income tax evasion or any other offence which may
affect underwriters’ judgement as to whether they wish to accept business
from your firm?
Yes ☐
No ☐
Yes ☐
No ☐
Yes ☐
No ☐
1.22 Has your firm or any of its current directors, partners, proprietors, principal
officers or key senior members of staff ever been the subject of a voluntary
arrangement with creditors or any insolvency proceedings (e.g.
administration, liquidation or bankruptcy)?
1.23 Has your firm, or any of its current employees, partners or directors ever had
its/his/her business licence (s) suspended or revoked or re-licensing
refused?
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1.24 Has your firm’s membership of any association ever been declined, cancelled
or withdrawn?
Yes ☐
No ☐
Yes ☐
No ☐
Yes ☐
No ☐
1.25 Has your firm, or any of its directors, partners, proprietors, principal officers
or key senior members of staff been censured, fined or had conditions
imposed by any external insurance regulator?
1.26 If you have answered yes to any of the questions above please provide details
2 Lloyd’s information
2.12 Do you currently transact business with Lloyd’s through a registered
Lloyd’s broker(s)?
If yes, please provide the name of the broker(s):
2.13
Does your firm intend to handle any of the following types of business (please select all that apply)?
Retail
☐
Wholesale
☐
Reinsurance
☐
Outwards reinsurance
☐
Binding authorities
☐
Please note that if you intend to place binding authority business you will not be able to do so without first receiving
sign off from Xchanging and Lloyd’s Delegated Authorities Team. (This may require you to complete additional
training.)
Lloyd’s Broker Registration Application Form
Copyright © Lloyd's 2013
14
3 Summary financial information
Please include currency used where applicable and ensure that the latest set of audited accounts have been included
with this application form
3.1 Financial year end (format DD/MM/YYYY)
3.2 Date of last audited financial statements
(format DD/MM/YYYY)
3.3 Name of auditor
Address of auditor
Address
Postcode / Zipcode
Country
3.4 Are your auditors qualified to conduct financial audits in accordance with
local requirements?
Yes ☐
No ☐
Yes ☐
No ☐
3.5 Name of regulatory body auditors are registered with
3.6 Please state your profit/loss for the last year of audited
accounts
3.7 Please state the profit/loss projected for the current year of
account for which audited accounts are not yet available
(it may assist your answer to submit a summary of your budget
for the current year)
3.8 Please state amount of paid up (paid in) share capital
(please show currency used)
3.9 Please state the value of intangible assets, such as
goodwill (please show currency used)
3.10 Are two signatories required on payments drawn on
any insurance accounts?
3.11 As per the firms last audited financial statements please show the following information
Insurance debtors due within 3 months
Insurance debtors due within 4-12 months
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Insurance debtors due later than 1 year
Total insurance debtors
Total insurance creditors
Provision for bad debts
3.12 What provision for bad debts has been made since the
last audited financial statements?
3.13 Are these accounts subject to any charge or lien?
If yes, please provide details in 3.15 below
3.14 Is your firm dependent on a guarantee to support its solvency?
If yes, please provide details in 3.15 below
3.15
Yes ☐
No ☐
Yes ☐
No ☐
If there have been any developments subsequent to your latest financial statements supplied that could
materially affect the financial condition of you firm beneficially or adversely, please explain below
Lloyd’s Broker Registration Application Form
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4 NON EU applicants checklist
Applicants must ensure that all documentation listed below is included with their formal submission or the
review and approval process will be delayed.
1
Completed and signed application form, including a copy of Annex B completed for
every individual listed in 1.14
☐
2
Structure chart of the group (up to the ultimate holding company) of which the applicant
is part, showing directors/partners of the group and all shareholdings over 10%
☐
3
Structure chart of the applicant showing directors/partners and shareholders (over 10%)
☐
4
2 years of audited financial statements
☐
5
Evidence of membership or authorisation from the relevant regulatory body
☐
6
Copies of Professional Indemnity insurance certificate and full policy wording confirming
compliance with Lloyd’s requirements
☐
7
Confirmation from your bank that Lloyd’s client monies will be held in strictly segregated
client money accounts
☐
8
Business rationale for becoming a Lloyd’s broker which should include details of the
type of business you will bring to the market and how you intend to operate.
☐
9
Completed Forecast Premium Template
☐
Formal applications are invited by Lloyd’s once each of the above areas has been addressed. As explained in
section 2 of the guide for applicants, there are three further areas where confirmations must be provided
before you may become a registered broker at Lloyd’s. Obtaining these confirmations is typically the most
time consuming part of the registration process and in view of this, applications are invited while work is still
underway in these areas. These are as follows: -
10
Letter of support from at least 3 managing agents, confirming that they are willing to
enter into a terms of business agreement with your firm in the event of your successful
registration as a Lloyd’s broker (to be signed by a director of the managing agent)
11
Confirmation from Xchanging that your firm (or nominated outsource provider) is able to
operate the necessary accounting and settlement and claims advice and settlement
processes to transact at Lloyd’s and that Xchanging has received all necessary
documentation to set up and support such processing (please refer to the separate
Xchanging Application Information Pack for more details)
12
If you intend to place binding authority business in the Lloyd’s market, confirmation from
Xchanging and Lloyd’s Delegated Authorities Team that you have the necessary
procedures and personnel to place and administer this type of business effectively.
☐
☐
☐
Lloyd’s Broker Registration Application Form
Copyright © Lloyd's 2013
17
ANNEX B: KEY INDIVIDUAL DETAILS FOR NON-EU FIRMS
(To be completed and submitted with the Lloyd’s Broker Registration Application Form by non-EU applicants)
Please complete a copy of this form for every individual identified in section 1.14 of the Lloyd’s broker registration
application form and attach a brief CV in each case.
Surname
Forename
Former, or other name(s) used, e.g. maiden or
married name
Date of change (format DD/MM/YYYY)
Date of birth (format DD/MM/YYYY)
Position / job title
Appointment date (format DD/MM/YYYY)
%
Percentage ownership of applicant
Based on a normal five day working week approximately what percentage of your time is
spent on the affairs of the applicant?
%
Home address
Address
Postcode / Zipcode
Country
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Please provide details of any professional or business qualification held
Qualification
Date obtained
If the individual has ever worked in the Lloyd’s market as a broker or underwriter, or has held a Lloyd’s
pass please provide details.
Name of firm
Comments
This individual would like access to the underwriting room at Lloyd’s.
(Please note, a nominal fee applies to all applications for a room pass.)
Yes ☐
No ☐
Lloyd’s Broker Registration Application Form
Copyright © Lloyd's 2013