* Indicates a required field Name of applicant Company* Trading Names (if any) Address* Telephone number* Email* Date Trading commenced* Registered Number* Registered Office* Please provide the following information in respect of all shareholders * Officer Name Position No of shares %age of equity Please select as appropriate where the applicant or any Director, Principal, Partner or Senior Employee:* Has been involved in liquidation or bankruptcy proceedings on his/their own account, or on account of any firm or company with which he/they were at the time connected as a Director, Principal or Partner or had judgement awarded against him/them Has had any order made against him/them under the Companies Acts or Insolvency Acts Has had any High Court or County Court judgements made against him/them Has any unsatisfied County Court Judgements Please enter details where appropriate Year End* Auditors name and address* Auditor's telephone* Auditor's facsimile Professional Indemnity insurance Name of Insurer* Policy Number* Limit of Indemnity* £ Excess £ Renewal Date (Please enclose a copy of your current PI Certificate detailing above. Your Application cannot be processed without this document. Minimum cover required: £250,000) Note to all applicants: It is mandatory for all ATII Members to operate Client/Insurance Business Accounts Representative who will attend ATII Meetings. Alternative Name Declaration: It is declared that: a. The applicant carries on business as a supplier of travel insurance and either the applicant is a Lloyds Broker or at least 25% of its brokerage is derived from the supply of travel insurance facilities. b. The applicant will comply with the requirements of the Association's Memorandum and Articles of Association, a copy of which will be supplied to the Member upon his/its appointment as a member of the Association, or earlier on request. TO: The Secretary The Association of Travel Insurance Intermediaries Ltd Dear Sir, I/we hereby apply for membership of the Association of Travel Insurance Intermediaries Limited ("the Association") subject to its Articles and Memorandum of Association. Words and expressions defined therein shall have the same meaning in this Application. I/we undertake to contribute to the assets of the Association in the event of its being wound up while I/We am/are a member, or within (1) year afterwards, for payment of the debt and liabilities of the Association contracted before I/we cease to be a member, and of the costs, charges and expenses of winding up, and for the adjustment of the rights of the contributors amongst themselves, such amount as may be required, not exceeding one pound (£1); or in case of my/our liability becoming unlimited, such other amount as may be required in pursuance of Clause 5 of the Memorandum of Association. I/we acknowledge that the Association may impose conditions, including the execution of certain undertakings and guarantees, on my/our membership of the Association. I/we represent unto the association that the matters set out in the attached Membership Application Questionnaire hereto are true to the best of my/our knowledge and belief. Subject to aforesaid, I/we authorise you to enter my/our name(s) in the Register of Members as members of the Association pursuant to this application.