PSD2 Insurance Quotation

Please complete this short Statement of Facts to receive your individual insurance quotation.

If you would like to learn more about the insurance coverage visit PSD2 Insurance.

Statement of Facts

Completion of this proposal does not bind the undersigned to purchase or the insurer to issue a policy

Please complete the proposal form for all entities for which cover is required under this policy and confirm that:

To the best of your knowledge and belief, the information provided by you or on your behalf including the statements set out below are true, accurate and complete; and
You have disclosed all information relating to you or your business that is material to your application.

1. Your Contact DetailsEdit
- Title
- First Name
- Last Name
- Job title
- Telephone number
- Email address
Next
2. Your companyEdit
- Company name
- Address line 1
- Address line 2
- Town/City
- County
- Postcode
- Country
- When was the company established?
- Your company’s website address
  
  E.g. www.example.com
- Total turnover - last full financial year:
  
  Please enter numbers only.
- Total turnover - current projected financial year:
  
  Please enter numbers only.
- Total turnover - next full projected financial year:
  
  Please enter numbers only.
- Projected total income derived from PISP/AISP activities for the forthcoming year:
  
  Please enter numbers only.
- Total number of directors, partners, members and employees:
  
  Please enter numbers only.
Next
3. Business activitiesEdit
- Please confirm your Payment Services business activity
- Other business activity
- If you are applying for PISP permissions then please confirm:
- Number of merchants with whom you will enter into a contract
  
  Please enter numbers only.
- Number of payment transactions initiated by the undertaking that applies for authorisation to provide Payment Initiation Services in the last 12 months
  
  Please enter numbers only.
- Total value of all transactions initiated by the undertaking in the last 12 months?
  
  Please enter numbers only.
- If you are applying for AISP permission then please confirm:
- Number of different payment accounts accessed by the undertaking that applies for registration to provide Account Information Services in the last 12 months
  
  Please enter numbers only.
- Number of clients that made use of the AIS in the last 12 months?
  
  Please enter numbers only.
- Please provide a full description of your business activities
- Is Professional Indemnity/Data Security insurance required for all your business activities or PSD2 only?
  - All Activities
  - PSD2 only
Next
4. Statement of FactsEdit
- In providing the Information in the Statement of Facts, you confirm that it is accurate whether it has been provided by you or others on your behalf.
  
  Ensure that you read the questions and confirm that all facts are accurate and complete. If any information provided needs amendment then you must inform us before the start of the period of insurance.
  
  If there are any changes to the information during the period of insurance please inform us immediately and we will then notify you if this affects your policy. If you do not inform us of any changes it may affect any claim you make or result in your insurance being invalid.
  
  Please agree or disagree with the following points (note, when we say "you", we refer to the proposed insured company"):
- You are a UK-Registered Company/LLP/partnership.
  - No
  - Yes
- You are either an Appointed Representative, Directly Authorised by the FCA, going through or have applied for FCA authorisation.
  - No
  - Yes
- You are or will be acting in accordance with your minimum capital requirements as defined by the FCA.
  - No
  - Yes
- The majority of your customers are either UK or European domiciled and no more than 20% of your total revenue is derived from North American domiciled customers.
  - No
  - Yes
- You do not enter into Agreements which are subject to the jurisdiction of the US/Canadian Courts.
  - No
  - Yes
- You do not authorise any Director/Partner/Employee to sign cheques or make bank transfers on their sole signature in respect of client accounts for amounts above £50,000.
  - No
  - Yes
- You operate in the EU only.
  - No
  - Yes
- Strong Authentication - All customer records with sensitive data are encrypted, including but not limited to those held on your network, in transit, outside of your network, mobile computing devices or portable storage media.
  - No
  - Yes
- Please provide further information for the questions that you answered no to:
Next
5. Cover RequirementsEdit
- Please advise the limit of indemnity for which you require a quotation by ticking the relevant boxes. If you would like us to provide options e.g. £1m and £2m, then please choose £specify and put the options you require in the freetype box.
- Professional Indemnity / Data Security
  - £500,000
  - £1m
  - £2m
  - £specify
- Please specify the limit you require
- Directors’ & Officers’ Liability
  - not required
  - £500,000
  - £1m
  - £2m
  - £specify
- Please specify the limit you require
- Office Contents
  - No
  - Yes
- Office contents sum insured
- Employers’ Liability
  - No
  - Yes
- Number of employees
- Annual wageroll
- Public Liability
  - No
  - Yes
Next
6. Claims ExperienceEdit
- In the last ten years have there been any claims or investigations made against you, your directors, partners, members, officers or employees?
  - No
  - Yes
- In the last ten years have there been any losses sustained by you, which may have been covered by this insurance had it been in force.
  - No
  - Yes
- Can you please provide further information in respect of each claim, investigation or loss:
  
  1) Date
  
  2) Brief description of the nature of the claim, investigation or loss
  
  3) Values of any payments made or current estimate of loss
  
  4) Measures taken to prevent a reoccurence
- Claim Description
- Claim Description File Help
  
  .zip or .pdf extensions only. Max allowed size is 10MB.
Next
7. DeclarationEdit
- Material information
  
  It is your duty to disclose all material facts to insurers. A material fact is one which may influence an insurer’s judgement in its consideration of your proposal. If any of the statements above are incorrect, you must contact Protean Risk and ensure that they pass that information on to Insurers immediately. Insurers reserve the right, in accordance with the terms of your Policy, to amend the Premium and/or terms and conditions or cancel your Policy if there is a material inaccuracy in this information.
  
  Your information
  
  Here at Protean Risk we take your privacy seriously and will only use your personal information to provide your PSD2 insurance quotation and for our legitimate business interests. Click here to learn more about these interests and when we may process your information in this way.
  
  We will never share, rent or pass your information to any third parties other than insurance companies quoting for and providing your PSD2 insurance and only then when you have specifically instructed us to seek insurance terms or obtain insurance cover on your behalf.
  
  Next steps
  
  Protean Risk will provide a quotation based on your responses but we will require some additional information in order to put the insurance in place and you will be advised of this with our quotation.
- I/we confirm that the information given in this PSD2 Insurance Form is correct, accurate and complete and I have made a fair presentation of the risk
- I agree to your Terms & Conditions and the use of my personal information as explained in your Privacy Policy
- Signature
  
  Please enter your initials.
By submitting this form you are confirming all details are correct and this form is complete.
Submit

Need help?

T: 020 3763 5340
E: info@proteanrisk.com

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