Application for directly authorised firms who only want to refer business

Application for Directly Authorised Firms who want to refer business only. This form must only be completed by firms who are directly authorised by the Financial Conduct Authority (FCA).

If you need any help completing this form please contact our Intermediary Sales Team on 0345 0615 700 Mon-Fri 9:00am-5:00pm, use the webchat button at the bottom right of your screen or our contact form. All information supplied on this form will be checked. If we’re missing anything, we’ll contact you to let you know.

Please note that completion of this application form will provide access to Paymentshield referral proposition. All information supplied on this form will be subject to verification. We may require you to provide further information. False, inaccurate or misleading information will lead to the application being rejected. Completing this form in full will enable us to set up your agency and begin paying commission in a timely manner. 

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Firm details 

Can you confirm that your firm holds current professional indemnity cover? *
Is your trading address different from your firms registered address? *

Help text: We will send all correspondence to this address.

Main contact at the firm who Paymentshield should discuss the application with

Additional controller information

A controller is the controller, owner, partner or director of the firm.
Add an additional controller

Legal status of firm

Product Information

Is general insurance (GI) your firm's primary activity? *

Are more than 15% of your customers classed as vulnerable as described by the FCA? *

Have you/or the company been selling general insurance for longer than 12 months? *

Banking details

This must match the firm’s name as stated in section one.

Commission Details
Confirmation of the referral fee will automatically be sent to the company's email address stated in section 1, unless alternative email address supplied in the box below
When establishing a new agency with Paymentshield your method of commission will default to annualised indemnity. If you wish to receive your commission payment for Paymentshield as an alternative to annualised indemnity, please select your preferred method below:
Preferred indemnity option


Has the firm had a receiver or administrator appointed, failed to satisfy a debt or reached an arrangement with any of its creditors or had a petition for bankruptcy or compulsory winding up of the firm? *

Has the firm or any of its controllers at any time been convicted of fraud or other dishonesty, or any offence under legislation, or sanctioned by a regulatory body? *

Are there any other significant events regarding the firm or any companies in the firm’s group that might adversely affect this application? *

I can confirm that my company holds the following permissions through the FCA: arranging (bringing about) deals in investments, retail (non-investment insurance)

Declaration and data protection notification

Data protection notice

The personal information provided in this form may be “personal data” as defined in the current UK Data Protection Legislation
(UK GDPR and Data Protection Act 2018) and will be used by Paymentshield Limited. We may obtain further personal data about
you or your company from credit reference agencies, the Financial Conduct Authority (FCA) and/or other regulatory bodies. We
will use this information to decide whether to enter into the agreement with the company and then periodically whether to
continue with the agreement. We may use the information to administer our agreement with the company.

We may share all information we have about you with insurance companies, credit reference agencies, debt recovery agencies,
tracing services, the FCA and/or other regulatory bodies in order to protect our and others’ interests, and to prevent fraud. We may
use information that is not sensitive personal data as defined by the DPA for marketing purposes, and may share this information
within the Atlanta Group. 

When you provide us with this information you are consenting to our use of it as set out in this notice and that all conditions in the Data Protection Annex will be followed and adhered to. If you have questions about our use of personal information, or if you believe our records are inaccurate, you should write to the Data Protection Officer, Paymentshield Limited, Embankment West Tower, 101 Cathedral Approach, Salford, M3 7FB or email [email protected].

I confirm that I have read and understand the above data protection notice *

I, as stated in the controller section, can confirm I am the controller, owner, partner or director of the firm and the information in this form is complete and correct to the best of my knowledge, information and belief, and that there are no relevant facts of which the Paymentshield Group of companies and or alliance partners should be aware of *

I confirm that I have read the Agency Terms & Conditions and I hereby agree on behalf of the firm to be bound and comply with the obligations and requirements contained therein *