Source Brokers Membership Application
Name
*
First Name
Last Name
Full Registered Company & Trading Name(s)
*
Who are the beneficial owners of the business - please give full details
*
Please detail all shareholders and directors of the business
*
Address
*
Addresss Line 1
Address Line 2
City
County
Eircode
Email
*
example@example.com
Your Mobile Number
*
Number of Offices
*
Total Number of Staff
*
Back
Next
Please Provide a Breakdown for Each Policy Type
*
Number of Policies
Total GWP
Main Insurer
Private Motor
Commercial Motor
Home
Farm
Fleet
Other Commercial Business
Life
Other
TOTALS
Back
Next
Do you foresee any change in the directorship of the company over the next 3 years?
*
Yes
No
Do you wholesale any products?
*
Yes
No
If yes - please provide details of products you wholesale
*
Would you be willing to offer an agency to all Source members for these products?
*
Yes
No
Do you have access to any special insurance schemes?
*
Yes
No
If yes - please provide details of any schemes you operate or have access too
*
What is your Mission Statement or main goals & policies?
*
What is your main aim for the next 3 years?
*
Back
Next
Will you commit to suppling the above breakdown of your business if and when it is required or at a minimum once a year?
*
Yes
No
What do you feel you can bring to the Source Group
*
Can you commit to a minimum of yourself or 1 member of staff attending every source meeting (approx. 3 face to face and 2 zoom per year)?
*
Yes
No
Who is your main software provider?
*
Do you foresee this changing in the next few years?
*
Yes
No
What other insurance software do you use: (e.g. comquote, Applied Home, Riskhandler)
*
How did you first hear about Source
*
Would you support branded products of Source
*
Yes
No
If required would you give of your time or a staff members time to develop Source Projects?
*
Yes
No
Are you a member of any other Broker Network
*
Yes
No
If yes, please specify
*
Submit
Should be Empty: