New Agency Application Form

Please complete the Agency Details Form and then click on the Send Application button below: Fields maked by * are mandatory.

Agency Name in full * Trading Name (if difference from above) Type of business * Company Registration Number

Trading Address * Postcode *

* Click to enter different registered / head office addresses.

Number of Branches Telephone Number * Fax Number Website Address

Daily Contact Name Job Title Daily Contact Email Address *

Professional Indemnity Insurance details

If available please provide details of your professional indemnity insurance poliy

Profession Indemnity Insurance Professional Indemnity Insurer *

Renewal Date

Regulatory Compliance details

Compliance Contact Name Job Title Compliance Email Address

Yes

No

Are you fully authorised with the FCA for insurance sales *

If No, please continue to complete this application, however we will need to contact you with regards to further verification details. FCA Authorisation No

Are you a member of a Broker Network?

Yes

Please enter any additional information here