Join amii

Application form.

New Member Application Form 2025/26.

To join us, please complete the application form below. Please note, you will need to upload a copy of your current Professional Indemnity Certificate of Insurance. Upon receipt of your application form you will be issued an invoice along with the amii bank details for payment of the £150 application fee. When payment is received the application process will then commence.

Company Name

Name of Principal(s)

Position(s) Held

Address (inc postcode)

Contact Name(s) & Job title for Correspondence

Telephone Number

Contact Email Address

ICO Registration Number

Date Business established

Website Address (please use https://)

Are you directly Authorised by the FCA or an Appointed Representative?

Directly Authorised Appointed Representative

Please supply your FCA Authorisation number

If an Appointed Representative, please supply the name of the Principal business and their Authorisation number

Is the Principal person (as listed above) an Approved person with the FCA?

Yes No

Please state the person in your company with the Apportionment and Oversight Function

No. of years PMI experience

No. of PMI Sales Staff

No. of PMI Insurer Agencies held

No. of PMI Sub Agents

Please provide Agency Numbers for at least six health insurers that you hold active agencies with

Allianz Partners

April International

AVIVA Health

AXA Health

AXA - Global Healthcare

BHSF

BUPA

BUPA Global

Cigna International

Expacare

The Exeter

Freedom Health

Health Compass

Health-on-Line

Heath Westfield

Medicash

Morgan Price International

Now Health Simply

PHC

WPA

Other

Have you had any Agencies withdrawn in the last 3 years?

Yes No

If YES, please state the reason why

Do either (a) any Directors of your brokerage have any connection with an insurer?

Yes No

Or (b) is the brokerage tied, for any reason, to an insurer?

Yes No

If YES, please give details

Have you, or any principal, director or partner under a current or previous trading title: (a) been declared bankrupt or insolvent (b) been convicted of any criminal offence (other than motoring offences); or (c) had any fine or sanction imposed by the FCA or predecessors?

Yes No

If YES, please give details

Please indicate the approximate value of your Group, Individual & International Private Medical Insurance annual premium placed less IPT (API) in one of the bands below (PREMIUM income, NOT commission. Do not include other forms of insurance)

£0 - £2 million (Annual m/ship fee: £300 + VAT) £2 - £5 million (Annual m/ship fee: £500 + VAT) £5 - £10 million (Annual m/ship fee: £700 + VAT) £10 million + (Annual m/ship fee: £1,100 + VAT)

This figure will be used to assess your Annual Membership Fee. You are responsible for notifying amii when this changes.

Approximate split of PMI business

% SME/Corp

% Individual

Approximate number of clients

% SME/Corp

% Individual

Please name your Professional Indemnity Insurer

Approximate percentage of your business is PMI

Please detail any insurance you may sell aside from Private Medical Insurance

Please upload a copy of your current Professional Indemnity Certificate of Insurance

The information you give will be held and used by amii to process your membership application and provide membership services, including invitations to meetings and events. Other carefully selected organisations may be allowed access to sufficient information to enable amii to offer you membership services through these organisations. PLEASE TICK THE BOX if you DO NOT consent to your company information being shared by amii in this way.

I/We are applying for full membership in the Association of Medical Insurers and Intermediaries and consent to six references being taken as stated in this application in support of our application.

I/We agree to be bound by the Constitution and Code of Conduct of amii.

I/We agree that at least one representative from our business will attend the amii Summits.

I/We consent to our details appearing in the amii Members Directory and on the 'Find-An-Expert' section of the amii website. (If you do NOT wish to appear in these publications, tick this box)

I/We will pay our Application Fee of £125+ VAT to the amii bank account. I/We understand that we will be invoiced for the pro-rata Membership Fee on acceptance of our application and that the minimum term is 12 months upon joining.

I/We understand that amii membership acceptance and fees payable relate exclusively to the applicant's company nameonly. I/We understand that our amii membership is not transferable or permissible to extend to other companies within ourgroup or appointed representatives that do not exclusively operate under the same name as our company.

I declare that the information I have given in this application form is true and accurate.

Name

Position

Date

Join amii

Application form.

New Member Application Form 2025/26.

Join us today to discover the benefits

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