Intermediary Application "*" indicates required fields Step 1 of 11 9% Welcome to Cinagi Intermediary application process. During this process we will require you to complete all the details required by our underwriter Infiniti Insurance to formally assess your application. There are quite a few legislative requirements that will need to be completed and attached for the underwriter's review. To make things easier, you can save your application at any point and return at a later stage as we know it might take a bit of time to gather all requirements. Once completed your application will be assessed and should your application be successful we will provide you with a formal Intermediary Agreement to be signed. Responsible PersonPersonal Detail* First name Surname Designation*Mobile Number*Alternative NumberEmail* Intermediary InformationTrading name*Previous Trading NameDate business was established or incorporatedDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Type of Business: Limited Liability Company Close Corporation Sole Proprietor Partnership Other Business Registration NumberID Number of OwnerName,Surname and ID numbers of partnersPlease provide more detail on the type of businessPostal Address Street Address City ZIP / Postal Code Physical Address Street Address Address Line 2 City Province Postal code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website E-mail address for person responsible for updating intermediary details/agreement Income Tax numberVAT Number FAIS License DetailsFSP License Number*Date license was obtainedDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920License Categories you are accredited for* Category I Category II – Discretionary FSP Category IIA – Hedge Fund FSP Category III – Administrative FSP Category IV – Assistance Business FSP Category I sub categories Long term Insurance: Sub Category A Short term Insurance: Personal Lines Long term Insurance: Category B1 Long term Insurance: Category B2 Long term Insurance: Category C Retail Pension Fund Benefits Short term Insurance: Commercial Lines Pension Fund Benefits Securities and Instruments: Shares Securities and Instruments Collective Investment Schemes Foreign Currency Denominated Investments Health Service Benefits Long-term Deposits Short-term Deposits Friendly Society Benefits Category II – Discretionary FSP Long-term Insurance subcategory B1 Long-term Insurance subcategory C Retail Pension Benefits Pension Fund Benefits (excluding retail pension benefits) Securities and Instruments: Shares Securities and Instruments: Money market instruments Securities and Instruments: Debentures and securitised debt Securities and Instruments: Warrants, certificates and other instruments acknowledging, conferring or creating rights to subscribe to, acquire, dispose of, or convert securities and instruments referred to in subcategories 2.5, 2.6 and 2.7 Securities and Instruments: Bonds Securities and Instruments: Derivative instruments excluding warrants Participatory Interests in Collective Investment Schemes Forex Investment Business Long-term Deposits Short-term Deposits Category IIA – Hedge Fund FSP Long-term Insurance subcategory B2 Category III – Administrative FSP Long-term Insurance: subcategory B1 Long-term Insurance: subcategory C Retail Pension Benefits Pension Fund Benefits (excluding retail pension benefits) Securities and Instruments: Shares Securities and Instruments: Money market instruments Securities and Instruments: Debentures and securitised debt Securities and Instruments: Warrants, certificates and other instruments acknowledging, conferring or creating rights to subscribe to, acquire, dispose of, or convert securities and instruments referred to in subcategories 3.5, 3.6 and 3.7 a Securities and Instruments: Bonds Securities and Instruments: Derivative instruments excluding warrants Participatory Interests in Collective Investment Schemes Forex investment business Long-term Deposits Short-term Deposits Long-term Insurance subcategory B2 Are there any restrictions placed on this license? Yes No Number of KI's registered on this licensePlease enter a number from 1 to 99.Are any of the representatives, Juristic Representatives?* Yes No Please provide Details Compliance OfficerDetails of compliance officer* First name Surname Email Address* Phone Personal Indemnity CoverUnderwriter*Policy Number*Limit of Indemnity*Policy Inception Date*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Expiry or Renewal Date*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Banking DetailsBank*Account Type*ChequeSavingsTransmissionBranch Code*Account Number*E-mail address for submission of all commission statements* E-mail address to send notifications of unpaid premiums Current ArrangementsList the names of any Insurance company and / or Underwriting Managers with whom you are authorised to place business with.Insurer 1Insurer 2Insurer 3 Have any of the organisations key personnel (Including all KI's and Reps), ever been declared insolvent, placed in liquidation whether provisional or final or reached a compromise with creditors. Yes No DetailsAre there any defaults and/or judgments against any of the organisations key personnel (Including all KI's and Reps) ?* Yes No DetailsDo any of the organisations key personnel (Including all Ki’s and Reps, have any pending or criminal convictions or paid an admission of guilt fine other than speeding or parking offences?* Yes No DetailsHas the company or any of the Partners/Members/Directors had any insurance intermediary agreement cancelled?* Yes No DetailsAre there any material facts that are likely to influence the assessment of this application which will affect the decision made by Cinagi and/or Infiniti Insurance Limited (INFINITI) with regard to whether we do business with you or not ? If there are in any doubt as to whether a fact would be considered material, you should declare/explain it in order for us to make an informed decision.* Yes No Details Supporting DocumentsPlease note any relevant information or attach any document to support this application. Below is a list of all the relevant documents we require to be uploaded in order to assess this applicationCopy of Company registration certificate*Max. file size: 2 GB.Copy of FAIS FSP licence and annexures (including indication of authorised categories)*Max. file size: 2 GB.Copy of VAT registration/ clearance certificateMax. file size: 2 GB.Confirmation of banking details for payment of commissionMax. file size: 2 GB.Copy of KI & Representative register (indicate any Reps under supervision)*Max. file size: 2 GB.Copy of KI & Representative competence register (indicate product training & CPD hours within current CPD cycle)Max. file size: 2 GB.Copy of policy schedule or proof of Professional Indemnity cover for FSP*Max. file size: 2 GB.Copy of policy schedule or proof of Fidelity cover (where applicable)Max. file size: 2 GB.If collecting premium – copy of the Collection agent’s SLAMax. file size: 2 GB.Proof of guarantee or similar security if doing own premium collectionsMax. file size: 2 GB.Copy of TCF policy for the FSPMax. file size: 2 GB.Copy of Conflict of Interest Management Policy for FSP*Max. file size: 2 GB. Commitment to the following principles This Intermediary Agreement application is being entered into on the clear understanding of the following principles, which are of critical importance: Parties to conduct their affairs in accordance with all prevailing legislation, but over and above that, undertake to maintain high standards of honesty, integrity and transparency in their dealings with each other. The parties further agree to: maintain good administration and accounting standards and recognise that inefficiency in these areas ultimately result in problems for the business and the mutual relationship. work together for the mutual benefit of all concerned, whilst never compromising fair dealing, honesty and speedy service to the policyholder. advise of any conflicts as and when it happens. In the event of these principles being breached, either party has the right to give notice to the other cancelling the agreement with immediate effect. You further acknowledge that the sharing of information (including credit information) relating to intermediaries by Insurers is essential to enable the Insurance Industry to manage the business and to reduce the incidence of fraud, in the public interest. On behalf of yourself and on behalf of any person you represent herein, you hereby waive any right to privacy in any information provided by you or on your behalf in respect of the application to become an intermediary and you consent to such information being disclosed to any other insurance company or its agent. You also acknowledge that the information provided by you may be verified against other legitimate sources or databases. You also waive any rights of privacy and consent to the disclosure of any information relevant to this application concerning yourself.Consent* I/We hereby apply for appointment as an Intermediary in terms of the Independent Intermediaries Agreement and undertake to be bound by the terms and conditions thereof. I/We confirm that all of the information contained herein is true and correct and undertake to advise of any material changes that may in the future occur. Consent* I hereby authorise Cinagi (Pty) Ltd underwritten by Infiniti Insurance Limited to send relevant or important information directly to Policyholders when required to do so.* Important Notice: INFINITI will not accept responsibility for cover until written confirmation has been issued by Cinagi (Pty) Ltd of acceptance of this application. A formal Intermediary agreement will be entered into between INFINITI and yourselves, upon successful application and verification. Δ