Europ Assistance Partner Eligibility Check

Please fill out the form below, and our team will review your details and get back to you shortly.

Partner Eligibility Check Form – Agency

If you need assistance or have questions related to the Eligibility Check process, please reach out to our partnership team partnersupport@europ-assistance.co.nz.

1. Agency Name

2. New Zealand Business Number

3. Business address

4. Business website URL

5. Email address

6. Phone number

7. Please select your preferred payment method

On Account Credit Card

On Account - On account functionality allows agencies to issue polices and reconcile their remittance on a weekly statement
Credit Card - Referring to a client's credit card, a payment link will be sent to the email address entered for the policy holder once & we will make your commission payment via EFT to your below bank details. Please note that agency credit cards are not accepted.

8a. BSB Number

8b. Account number

Please upload a PDF copy of your Bank statement & proof of your Professional Indemnity Insurance for a minimum of $1 million (NZD)

Please upload files (pdf, doc, docx, ppt, jpg, gif)

9. Please enter the full name & email address of your team members (inclusive of Admin staff completing your agencies reconciliation). This will allow us to forward them their training links to get them ready to sell

10a. Do you have a Business Shareholder (s)

Yes (If 'Yes' please provide names in 10b) No (if 'No' then skip to 11a)

10b. Business Shareholder(s)

11a. Do you have a Director (s)

Yes (If 'Yes' please provide names in 11b) No (if 'No' then skip to 12)

11b. Full name of Director (s)

12. Agency Owner

13. Confirm if any personal information (related to travel insurance) will be transferred outside of New Zealand

Yes No

14. If you answered "Yes" to Q13, can you confirm that you have a Privacy Policy which you adhere to in order to ensure compliance with applicable privacy legislation?

15. If you answered "Yes" to Q13, can you confirm that you have a Privacy Policy which you adhere to in order to ensure compliance with applicable privacy legislation?

Yes No

16. Have you, your entity or any director, CEO, or individual involved in distributing the insurance product declared bankruptcy or have a negative credit score?

Yes No

17. Do you consent for Europ Assistance to run a credit/bankruptcy check?

Yes No

18. Do you declare that no director, CEO, or any person involved in distributing the insurance product has been found guilty of crimes or subjected to disciplinary measures related to financial, securities, or insurance activities, including fraud, financial crime, or other serious offences under company, bankruptcy, insolvency, or consumer protection laws.

Yes No

19. Do you provide consent for Europ Assistance Australia & New Zealand to conduct a criminal check?

Yes No

20. Do you consent, in your capacity as authorised representative of the entity, to Europ Assistance Australia's & New Zealand Privacy Policy and the processing of the entity/relevant personnel’s personal information in line with this policy?

Yes No

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Europ Assistance Partner Eligibility Check​

Partner Eligibility Check Form – Agency

Europ Assistance Partner Eligibility Check