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Broker company's full legal name*(Required)

Broker company registration number(Required)

Company registration website

Broker company registered address(Required)

Broker company business address if different

Broker company's ultimate beneficial owners including, parent, subsidiaries and associates(Required)

Broker company's principal contact person and position(Required)

Principle contact person's email address and telephone number(Required)

Regulated Status

In what country are you regulated as insurance broker:

What is your insurance registration number:

What is the website of Financial Inspection where you are regulated:

Professional Indemnity Insurance

Policy Holder:

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Limit of Liability

Aggregate for Policy period, including cost & expenses

Deductible if any

Policy Governing Law:

Jurisdiction:

Insurer

Distribution

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