Broker Signup

Trading Details

Full Trading Name
Full Business Description

Registered address of the Business

Address



Postcode  

Full trading address of the Business

Telephone Number
Fax Number
E-Mail Address
Please indicate type of business Public Limited
Private Limited
Partnership
Sole Trader
Date Commenced Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900  /  Month  /  Day
Date Incorporated Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900  /  Month  /  Day
Company registration number
Full trading name of any holding company
Address



Postcode

Please name any other associated companies
FSA Registration Number

Please provide details of your professional indemnity cover

Insurer
Limit of Indemnity
Policy number
Renewal date Year 2013 2012 2011 2010 2009 2008 2007  /  Month  /  Day
 Does your cover meet current FSA requirements? YesNo
Has your company or any of its principals/partners/directors ever held an Agency with ourselves previously? YesNo
Has your company or any of its principals/partners/directors ever had an insurance agency refused/terminated? YesNo
Has your company or any of its principals/partners/directors ever been involved in enforcement or disciplinary proceedings by the FSA or other regulatory body?YesNo

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Please give details of the principals/partners/directors

Note: Please provide your private address.

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Please give the name and address of your accountants.

Accountant Company Name
Address



Postcode  

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Please give the name and address of the your auditors.

Auditors Name
Address



Postcode

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Name three insurance companies with whom you hold credit agencies in order that we may obtain a reference.

Please Give the name of your Bankers

Name of Bankers
Sort Code
Address



Postcode  

Account Number
How long account held?

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Please state whether you intend to conduct business through sub-agents?YesNo  
If you wish to provide any additional information, please do so here

I authorise you to obtain such references as may be required. I confirm that all the above details are correct and that should any of this information change I will notify the company in writing of any changes as soon as these occur. I confirm that I am authorised to make this application on behalf of the applicant firm.
Name
Position Held