New Business Submission Sheet - REFERRAL TO IN HOUSE LIFE INSURANCE DESK

SUBMISSION DETAILS

Your name (name of Broker):

Group brand - please confirm who your Client approached:

CLIENT DETAILS

IS THIS CLIENT INTRODUCED VIA ONE OF OUR INTRODUCER PARTNERS? IF YES, PLEASE CONFIRM THE NAME OF THE INTRODUCER PARTNER, IF NO, PLEASE STATE "NO":

Client Name(s):

Client 'phone number:

Client email address:

PLEASE STATE THE NAME OF YOUR PREFERRED IN HOUSE LIFE INSURANCE BROKER - OR ALTERNATIVELY STATE "NO PREFERENCE":

CLIENT CONTACT INSTRUCTION:

REASON FOR LIFE INSURANCE:

PLEASE PROVIDE ANY ADDITIONAL INFORMATION HERE

SUPPORTING NOTES:

Please confirm:

I CONFIRM THAT I HAVE TOLD MY CLIENT THAT AN IN-HOUSE COLLEAGUE WILL BE CONTACTING THEM TO DISCUSS THEIR LIFE INSURANCE NEEDS

TOOLBOX ACCESS:

I AGREE FOR THE LIFE INSURANCE ADVISER TO ALSO HAVE ACCESS TO THIS CLIENT'S RECORDS ON TOOLBOX AND THAT THE FACT FIND, WORKFLOWS AND POLICY RECORDS ARE UP TO DATE TO ENSURE AN EFFICIENT USE OF DATA FOR THE PURPOSE OF THIS LIFE INSURANCE REVIEW.

REMUNERATION SHARE AGREEMENT:

I AGREE THAT MY DUE REMUNERATION SHARE WILL BE 25% OF THE COMMISSION RECEIVED BY THE SELLING ADVISER (WHETHER LUMP SUM / INDEMNITY, OR ON AN ACCRUAL / NON INDEMNITY BASIS). IF THERE IS A COMMISSION DUE TO AN INTRODUCER PARTNER, I UNDERSTAND THAT THEY RECEIVE THEIR REMUNERATION SHARE FIRST AND THE REMAINDER IS THEN SHARED BETWEEN H D CONSULTANTS, THE SELLING ADVISER AND MYSELF, AS IS USUAL STANDARD PRACTICE. I ALSO AGREE THAT IF THERE IS A POLICY CANCELLATION AND A COMMISSION CLAWBACK OCCURS THAT MY PRO RATA REMUNERATION SHARE OF ANY DUE COMMISSION CLAWBACK AMOUNTS WILL BE REPAID ACCORDINGLY.

NOTE - This referral is for the purpose of the specific life insurance requirement above only. Any other financial services needs and requirements, Client referrals and/or other indirect matters, which are raised during the life insurance review, will automatically be referred back to you. This is a stipulated no-cross-sale agreement between all parties.

NOTE - To save a copy of this NBSS REFERRAL for your own record, before clicking the Submit button below, click "CTRL + P" and save this page as a PDF document.

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Your home may be repossessed if you do not keep up repayments on your mortgage.

We normally charge a Professional Client Fee for mortgage advice. The amount will depend on your circumstances. A typical fee would be £500. The actual Professional Fee may be more or less than this, and is subject to a full Fact Find discussion and research process. H D Consultants is a trading name of Howard Reuben who are an Appointed Representative of PRIMIS Mortgage Network, a trading name of Personal Touch Financial Services Ltd. Personal Touch Financial Services Ltd is authorised and regulated by the Financial Conduct Authority.. Registered Office: Preston House, 163 High Street, Crowthorne, Berkshire, RG45 7AF. Registered in England & Wales. Company Registration Number 4952586. This site is for UK Consumers only. Website Terms and Conditions click here for our Privacy Policy. GDPR Privacy Policy - click here (PDF download / view) This site contains third party links. By clicking these links you will depart from the H D Consultants' regulated site. H D Consultants nor PRIMIS Mortgage Network is responsible for the accuracy of the information contained within the linked site. The Financial Conduct Authority does not regulate some of the services listed. H D Consultants, mortgage and life insurance advisers, is authorised by the FCA no 403701. Our in house Wills and Trusts Practice is a long standing Member of the Society of Will Writers and Estate Planning Practitioners.

FP Ref: 1436009 / exp 25.08.2025

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