PARTNER QUESTIONNAIRE

AFFILIATE PARTNER

Please complete the following in detail and attach all requested documentation with submission of this questionnaire.

COMPANY INFORMATION:

TYPE OF ORGANIZATION(Required)

BUSINESS REGISTRATION FILL IN THE FOLLOWING SECTIONS:

PRIMARY BUSINESS ADDRESS(Required)
(Street address, DO NOT list P.O. Box)
LIST OTHER DOMESTIC BUSINESS OFFICE ADDRESSES
LIST OTHER INTERNATIONAL BUSINESS OFFICE ADDRESSES(Required)
PRIMARY CONTACT NAME(Required)

INSURANCE LICENSED PRODUCERS - NATIONAL PRODUCER NUMBERS (IF APPLICABLE)

DOES THE COMPANY HOLD VALID PROFESSIONAL LIABILITY INSURANCE POLICY?
DOES THE COMPANY HOLD A CYBER LIABILITY INSURANCE POLICY?
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Max. file size: 16 MB.
    DIRECTORS AND OFFICERS(Required)
    First Name
    Surname
    Address
    Citizenship
    DOB (MM/DD/YYY)
     
    DO ANY OF THE INDIVIDUALS LISTED ABOVE OR ANY OF THEIR IMMEDIATE FAMILY MEMBERS CURRENTLY HOLD OR HAVE PREVIOUSLY HELD PUBLIC OFFICE OR PERFORM DUTIES FOR ANY DOMESTIC OR FOREIGN GOVERNMENT?
    ARE ANY PRINCIPALS, OWNERS, DIRECTORS OR OFFICERS RELATED TO A SANCTIONED PERSON?
    DO ANY OF THE INDIVIDUALS LISTED ABOVE, OR ANY OF THEIR IMMEDIATE FAMILY MEMBERS: (1)HOLD ANY POSITION IN ANY POLITICAL PARTY OR ARE THEY CANDIDATES FOR POLITICAL OFFICE?
    (2) BEEN SUSPENDED FROM DOING BUSINESS IN ANY CAPACITY
    (3) BEEN CHARGED OR INDICTED WITH A CRIMINAL ACT
    (4) BEEN THE SUBJECT OF ANY FRAUD, BRIBERY, OR MISREPRESENTATION INVESTIGATION
    (5) BEEN MENTIONED IN THE PRESS FOR HAVING BEEN INVOLVED IN AN IMPROPER ACTIVITY
    (6) HAD A BUSINESS RELATIONSHIP TERMINATED FOR ETHICAL OR LEGAL REASONS?

    CONSENT

    MM slash DD slash YYYY