Sign Up Your Broker Account

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  • Company
  • Company Contacts
  • Nature of Business
  • Firm Status & Background
  • Market Background
  • Criminal Convictions & Bankruptcy
  • Bank Details for Commission Payments
  • Account
  • Declaration

Company details:

Registry address

Address of correspondence

Address of correspondence is the same as Registry address

Step 1 - 9

Contacts:

Add contact:

Add Contact

Contact list:

Position Name Surname Email Phone Additional info

Step 2 - 9

Line of Business/Occupation:

Step 3 - 9

Firm Status & Background:

Yes No
Yes No

Step 4 - 9

Market Background:


0-50K EUR 100K EUR 100K+ EUR

Please indicate the approximate split of your business:

50%
50%

What is your estimate for the production of new business in the next 12 months?

Please list the other medical insurance companies that you represent? (If you have any special arrangements with any other medical insurance companies, please state what these are below)

Step 5 - 9

Criminal Convictions & Bankruptcy:

Yes No
Yes No
Yes No
Yes No

Step 6 - 9

Bank Details for Commission Payments:



Add bank account:

Add

Bank list:

Currency SWIFT code IBAN Number

Step 7 - 9

Login Account:

These information will be used to create an update to your login account.

This e-mail will be exclusively used to access your account

The password and account access details will be emailed to you upon approval.

Step 8 - 9

Declaration:

I hereby declare that the information provided in my application for registration as a broker with GoldenCare is true, accurate, and complete to the best of my knowledge and belief. I understand that any false, misleading, or fraudulent statements made in the application may result in the rejection of my registration and may also be subject to legal consequences.
I acknowledge that GoldenCare relies on the information provided in the application for evaluating my eligibility and suitability as a broker. I understand that the accuracy and completeness of this information are crucial for maintaining the integrity and credibility of GoldenCare.
I further affirm that I am aware of the legal implications associated with providing false or misleading information. I understand that such actions may constitute a criminal offense under applicable laws and regulations. I am committed to conducting my business activities with honesty, integrity, and professionalism, adhering to the highest ethical standards.
In the event that any of the information provided in my application changes or becomes inaccurate, I undertake to promptly notify GoldenCare of the changes or inaccuracies.
I acknowledge that GoldenCare reserves the right to verify the accuracy of the information provided in my application and conduct background checks as deemed necessary.
By signing below, I affirm that I have read and understood the above declaration, and I agree to comply with all the terms and conditions set forth by GoldenCare.

Step 9 - 9