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
*
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Please Provide a Breakdown for Each Policy Type
*
Rows
Number of Policies
Total GWP
Main Insurer
Private Motor
Commercial Motor
Home
Farm
Fleet
Other Commercial Business
Life
Other
TOTALS
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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?
*
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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
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