- Old Mutual International

Transcription

INTERMEDIARY REGISTRATION
APPLICATION –
OLD MUTUAL ISLE OF MAN/
OLD MUTUAL GUERNSEY
The Intermediary must be FAIS licenced to apply for Terms of Business with Old Mutual Isle of Man/Old Mutual Guernsey.
All sections must be fully completed.
If you are applying for Old Mutual Guernsey Terms of Business please also complete section D (Personal Questionnaire)
a Intermediary details
Please indicate type of intermediary: (3)
Sole Trader
Partnership
Limited Liability Company/Close Corporation
Publically owned Corporation/Bank
Registered name of
intermediary firm
Date established
DDMMYYYY
Trading name
(if different)
Registered office
address
Postcode
Country
Postcode
Country
Correspondence
address
(if different from above)
All client copy correspondence and commission statements will be sent to your correspondence address if different to your registered office address.
Telephone number
(incl area code)
Mobile
Telephone number
Facsimile number
(incl area code)
E-mail
address(es)
Website address
Main contact(s)
Have any of the directors/partners/principals been associated with a company which
was/is a registered intermediary with any companies within the Old Mutual Group? (3)
Yes
No
If yes, please give
details including broker
number
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B Regulatory information
1.
Has the intermediary, its employees, directors, principals or partners been involved in, or are you aware of
any current or pending action in respect of: (3)
Disqualification as a director or from acting in the management or conduct of the
affairs of any company?
Yes
No
Petition for bankruptcy or winding-up?
Yes
No
Civil or criminal litigation?
Yes
No
Legal judgements?
Yes
No
Appointment of a receiver/administrator/liquidator/business rescue practitioner?
Yes
No
Refusal of a licence to deal in securities?
Yes
No
Financial crime, including charges or convictions, relating to bribery?
Yes
No
Refusal by any insurance company or investment management organisation to grant
registration facilities or continue to accept business placed?
Yes
No
Refusal of membership of any regulatory body or withdrawal, cancellation
or suspension of an application from such a body?
Yes
No
A commission debt with a Financial Service Provider?
Yes
No
Being ordered to pay compensation to a client by a regulatory ombudsman?
Yes
No
Business rescue proceedings?
Yes
No
Notification that the intermediary is ‘financially distressed’ as defined in the
South African Companies Act 71 of 2008?
Yes
No
Please give full details of reasons for answering ‘Yes’ to any of the above questions - please continue on a separate sheet
if required.
2.
Please confirm your FAIS licence(s) category (3)
Category I
Category II
FAIS License Number
If your regulatory status changes you must advise Old Mutual Isle of Man/Old Mutual Guernsey immediately.
The company name on the regulatory licence should read the same as the name of the company applying for Terms of Business.
If the name differs please explain below and provide documentary evidence if appropriate.
3.
Is the intermediary regulated by any authority (governmental or otherwise) in addition to FAIS?
If yes, please state name of authority and membership details (including license number)
4.
Is the intermediary registered with, or a member of, a professional trade or body?
(If Yes, please state name of trade or body and supply registration number)
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Yes
No
Yes
No
B Regulatory informatioN (CONTINUED)
5. Please provide details of the compliance officer associated with the FAIS license detailed above.
a) Name of compliance officer
b) Compliance officer contact details
Telephone number
Facsimile number
(incl country & area code)
(incl country & area code)
Please note that intermediaries must not introduce business to any member of the Old Mutual Group which is subject
to legislation that would make it unlawful.
C COMMISSION PAYMENT DETAILS
Commission is paid by Telegraphic Transfer or Direct Credit (GBP) to a UK Bank in the payment currency, providing the balance is in excess of £500 for
Old Mutual Isle of Man and £100 for Old Mutual Guernsey (or the equivalent in a different currency):
Payments which are to include VAT, must be made to your South African Rand bank account.
Please note that Old Mutual International will not make payment to third parties.
Bank account details Rand (ZAR)
Account/Payee
name
Account number
Swift code
IBAN
(if available)
Bank name
Bank address
VAT
registration number
Bank account details US Dollar (USD)
Account/Payee
name
Account number
Swift code
IBAN
(if available)
Bank name
Bank address
(continued)
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C COMMISSION PAYMENT DETAILS (CONTINUED)
Bank account details Sterling (GBP)
Account/Payee name
Account number
Sort code
Swift code
IBAN
(if available)
Bank name
Bank address
Should you wish to supply further information or instructions, please provide on a separate sheet.
www.oldmutualinternational.com
Old Mutual Isle of Man, Branch of Old Mutual Life Assurance Company (South Africa) Limited, is registered in the Isle of Man under number 005664F and whose
principal place of business is King Edward Bay House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0)1624 653 400.
Fax: +44 (0)1624 622 296.
Authorised and regulated by the Isle of Man Insurance and Pensions Authority.
Old Mutual Guernsey is the trading name of Old Mutual Life Assurance Company (South Africa) Limited, Guernsey Branch.
Old Mutual Guernsey, whose principal place of business is Albert House, South Esplanade, St Peter Port, Guernsey, GY1 1AW, is a branch of Old Mutual Life
Assurance Company (South Africa) Limited, which is incorporated in South Africa (reg no. 1999/04643/06). Registered Office: Mutualpark, Jan Smuts Drive,
Pinelands, Cape Town, South Africa.
Old Mutual Guernsey is licensed by the Guernsey Financial Services Commission under The Insurance Business (Bailiwick of Guernsey) Law, 2002 to carry on long
term insurance business.
Old Mutual Life Assurance Company (South Africa) Limited is a registered long-term insurer and a licensed financial services provider.
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Only complete this section if you are applying for Old Mutual Guernsey Terms of Business
D PERSONAL QUESTIONNAIRE
To be completed by ALL partners, directors, principals and sole traders. Separate forms to be completed by each
individual. Please photocopy as required.
Please enclose an independently certified copy of the individuals’ passport or National ID card and verification of residential address
e.g. a certified copy of a utility bill (dated within the last three months).
Title (3)
Mr
Mrs
Miss
Other
(please specify)
Full name
‘the individual’
Passport/
ID no.
Position in
company
Date of birth
DDMMYYYY
Residential
address
Postcode
Country
How long have you lived at this address?
Details of financial services experience (most recent first)
Date from
M M Y Y
Company name
Date to
M M Y Y
Position held
Date from
M M Y Y
Company name
Date to
M M Y Y
Date from
M M Y Y
Company name
Date to
M M Y Y
Position held
Position held
Photocopy if necessary
Details of appropriate qualifications
Qualification
Date
M M Y Y
Qualification
Date
M M Y Y
Qualification
Date
M M Y Y
Qualification
Date
M M Y Y
Qualification
Date
M M Y Y
Qualification
Date
M M Y Y
I hereby declare that the statements made herein are true and correct.
I authorise Old Mutual International to request information from any person, body or institutes as may be necessary and I authorise Old Mutual
International to conduct a status enquiry search.
Signed
Date
DDMMYYYY
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D PERSONAL QUESTIONNAIRE (CONTINUED)
Personal bank account details
Account name
Account number
Sort code
Swift code
IBAN
(if available)
Bank name
Bank address
E WARRANTY
The Intermediary warrants:
(a) the introduction of business by the Intermediary to Old Mutual Isle of Man/Old Mutual Guernsey will not breach any legal obligation or laws of
any competent authority in any relevant jurisdiction,
(b) the intermediary has read, understood and agrees to the Terms of Business document, which was attached to the Intermediary Registration
Application provided. The conditions of the Terms of Business will be observed at all times,
(c) the Intermediary will at all times act only as the agent of the proposer and not for or on behalf of Old Mutual Isle of Man/Old Mutual Guernsey,
(d) the Intermediary will at all times maintain every obligatory licence, authorisation and registration and comply with or procure compliance by its
officers and agents, as appropriate, with all applicable laws and regulations of jurisdictions where it operates,
(e) the Intermediary has read and understood and will comply with all anti-money laundering/countering the financing of terrorism laws, regulations,
instructions, guidance or rules issued from time to time by the Guernsey Financial Services Commission (GFSC) or the Isle of Man Insurance and
Pensions Authority (IPA).
(f) the Intermediary has read and understood and will comply with the code of market conduct for independent Intermediaries that Old Mutual Isle
of Man/Old Mutual Guernsey, as a minimum, expects to be followed in the course of introducing Old Mutual Isle of Man/Old Mutual Guernsey
products to clients.
The GFSC website can be found at: www.gfsc.gg
The IPA website can be found at: www.ipa.gov.im
F Declaration
PLEASE PHOTOCOPY THIS SECTION IF REQUIRED
I/We hereby declare that the statements made herein are true and correct and shall form the application to place business with Old Mutual Isle of
Man/Old Mutual Guernsey.
If my/our intermediary registration application is accepted I/we acknowledge that dealings will be governed either by Old Mutual Isle of Man/or
Old Mutual Guernsey Terms of Business which I/we have read and understand and will at all times observe the conditions.
I/We authorise Old Mutual Isle of Man/Old Mutual Guernsey to request information or references from any person, body or institute as may be
necessary and I/we authorise Old Mutual Isle of Man/Old Mutual Guernsey to conduct a status enquiry search.
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F DeclaratION (CONTINUED)
I/we will comply with the regulatory requirements of the jurisdiction(s) of Old Mutual Isle of Man/Old Mutual Guernsey, the client and where business
is conducted, including any applicable laws and regulations relating to financial crime and bribery.
I/we will inform Old Mutual Isle of Man/Old Mutual Guernsey of changes to any of the information contained in this registration application.
I/we agree that Old Mutual Isle of Man/Old Mutual Guernsey will hold and use information relating to the intermediary, its employees, consultants,
directors, principals and partners (including personal data as defined under data protection legislation) for the purposes of setting up my/our Terms of
Business and continuing administration.
I/we agree that Old Mutual Isle of Man/Old Mutual Guernsey may share such information by any method, including e-mail with;
– other companies within the Old Mutual Group,
– other financial institutions or third parties for purposes connected with the business that the intermediary introduces to the company or for preparing
strategic or marketing plans,
– any appropriate regulatory authority, industry registers or databases, and
– other organisations including the police and fraud prevention agencies.
Signature(s)
Where a company, close corporation or partnership has more than one signatory, the form should be signed in accordance with the signing powers
outlined in the signatory list.
Signed
(Authorised
signatory)
Date
DDMMYYYY
Date
DDMMYYYY
Date
DDMMYYYY
Date
DDMMYYYY
Date
DDMMYYYY
Print name
Signed
(Authorised
signatory)
Print name
Signed
(Authorised
signatory)
Print name
Signed
(Authorised
signatory)
Print name
Signed
(Authorised
signatory)
Print name
Old Mutual Isle of Man, Branch of Old Mutual Life Assurance Company (South Africa) Limited, is registered in the Isle of Man under number 005664F and whose principal
place of business is King Edward Bay House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0)1624 653 400. Fax: +44 (0)1624 622 296.
Old Mutual Guernsey, whose principal place of business is Albert House, South Esplanade, St Peter Port, Guernsey, GY1 1AW, is a branch of Old Mutual Life Assurance
Company (South Africa) Limited, which is incorporated in South Africa (reg no. 1999/04643/06). Registered Office: Mutualpark, Jan Smuts Drive, Pinelands, Cape Town,
South Africa.
Old Mutual Guernsey is licensed by the Guernsey Financial Services Commission under The Insurance Business (Bailiwick of Guernsey) Law, 2002 to carry on long term
insurance business.
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F Declaration
(continued)
Internal use only
Acceptance by Old Mutual offshore specialist
Signed
Date
DDMMYYYY
Date
DDMMYYYY
Date
DDMMYYYY
Name
Branch
Confirmation by Old Mutual sales support
Signed
Name
Branch
Acceptance by Old Mutual Isle of Man/Old Mutual Guernsey
Signed
Name
South Africa.
insurance business.
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Secure Services Website application
This form only needs to be completed if the relevant parties do not already have access to the Secure Services
Website application.
Please follow this simple registration process to see the full range of services available from Old Mutual Secure Services Website, including access to the full
Old Mutual International client base associated with your business as well as details of commission payments.
By completing the form now you will be registered when we have issued your broker code.
Agreement to register on Old Mutual International Secure Services Website
Please use block capitals
Name
Title
E-mail address
Telephone/contact number
Name of business
Position within business
FAIS licence number
1. I understand the terms and conditions below, and I hold myself bound by them.
2. Where required by the context of the agreement or any other circumstances, singular may mean plural and vice versa, and the first person may
include shareholders, partners, representatives or employees of Old Mutual Isle of Man/Old Mutual Guernsey/the Financial Services Provider whom I
am authorised to represent.
3. I am a licensed Financial Services Provider, I am authorised to represent a licensed Financial Service Provider or I am an employee of a licensed
Financial Services Provider.
4. I, or the licensed Financial Services Provider whom I am authorised to represent, hold, or am applying for, Terms of Business with Old Mutual Isle of
Man/ Old Mutual Guernsey.
I acknowledge that:
• My use of the website and the information contained in it is at my own risk.
• I will only access information to which I am legally entitled, and will utilise information accessed on this site solely for the purposes of providing
financial advice and services. I will utilise such information in a way as not to infringe any rights conferred by the South African constitution and/or
legislation relating to privacy and data protection.
• I assume full responsibility and risk of loss resulting from the use of the Secure Services Website or the information it contains and I am responsible for
validating the integrity of any information received.
• I will not hold Old Mutual Isle of Man/Old Mutual Guernsey liable for any losses or damage arising from the use or reliance on the information
contained therein including, without limitation, any costs, claims or demands of any nature by any party, loss of profit or any other damages direct,
indirect or consequential.
• I will use the information retrieved from the service solely for my own purposes. I will not sell, resell, retransmit or otherwise make the information
retrieved from the services available in any manner or on any media to any third party unless I have obtained relevant prior written consent from
Old Mutual Isle of Man/Old Mutual Guernsey.
• I assume full responsibility and risk of loss resulting from anyone else, regardless of whether they are colleagues, representatives or employees of the
business gaining access to confidential information under the authority granted by this agreement.
• I undertake to inform Old Mutual Isle of Man/Old Mutual Guernsey immediately of any changes in respect of the shareholders, partners, representatives or
employees of the Financial Services Provider to whom access has been granted under this agreement.
• I undertake to inform Old Mutual Isle of Man/Old Mutual Guernsey immediately of any change in the relationship between myself and a client which
may or should result in a restriction or ceasing of the supply of information relating to that client.
• I indemnify Old Mutual Isle of Man/Old Mutual Guernsey. from any loss or consequence, financial or otherwise, which may result from the exercise of
access to information relating to any person under this agreement and/or using any code granted to me, whether or not authorised by me.
• Reference to the access details is specific to each individual and must not be shared with anyone.
Signature
Date
DDMMYYYY
Print name
South Africa.
insurance business.
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AUTHORISED SIGNATORY LIST
Please detail those people with signing powers below - photocopy if necessary.
If the Intermediary already holds an authorised signatory list confirming signing powers this can be supplied in place of
the below.
The intermediary must notify Old Mutual Isle of Man/Guernsey of any changes to the signatory list or any persons mentioned below.
If a full signatory list is not provided we will only accept instructions from the person signing this form.
This signatory list is the latest produced and contains up to date/current information (3)
If sole signatory, please tick and complete details for that individual
Yes
I am the sole signatory
Print Name
Sample
signature
Date
DDMMYYYY
Print Name
Signing
powers
Sample
signature
Date
DDMMYYYY
Date
DDMMYYYY
Date
DDMMYYYY
Print Name
Signing
powers
Sample
signature
Print Name
Signing
authority
Sample
signature
South Africa.
insurance business.
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FP0342

- Old Mutual International

Transcription

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