Registration of Interest

Your Name:

Broker Name:

Email Address:

Contact Number:

Position:

Date of Birth:

National Insurance Number:

Date business started trading:

Are you FCA registered?
YesNo

Membership Number:

Are you able to supply copies of latest set of accounts and current PI certificate?
YesNo

Have you ever been refused or deferred the granting of an agency?
YesNo

If yes, please provide the details:

Number of staff:

Please provide details of Directors/Partners/Owners:

Do you have sub agents advising or arranging insurance on your behalf?
YesNo

If yes, please provide the details:

Estimated Annual Policies:

Please provide details of the source of the business which you generate:

Do you have any Sub Agents and/or Appointed Representatives?
YesNo

If yes, please provide the details:

Your total gross written premium:

Comments: