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info@citybond.co.uk
0845 618 0345

New Agency Application

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

Agency Details
Agency Name in full*  
Trading Name
(if different from above)
Trading Address*  
   
   
 
Postcode*  
Type of Business*  
Company Registration No
Registered Address
(if different from above)
 
 
 
Postcode
Head Office Address
(if different from above)
 
 
 
Postcode
No of Branches
Telephone No*  
Fax No
Email Address*
(Your agency confirmation
will be emailed to this address)
 
Retype Email Address*  
Website Address
Daily Contact Name
Job Title
 
Professional Indemnity Insurance details
If available please provide details of your professional indemnity insurance policy.
Professional Indemnity Insurance
 
Regulatory Compliance details
If available, please supply
Contact Name (Compliance)
Job Title
Are you registered with
the FCA for insurance sales
FCA Authorisation No
Type of Agency*
Member of Trade Association
     
Other - please specify
Which schemes would you sell?
Net premium paid in last 12 months
Name of current broker / insurer
you are selling
Terms of Business Agreement
Please click here to read the Terms of Business Agreement (TOBA)
Tick to confirm you have read
and accepted the TOBA*
Where did you hear about Citybond?
What is the sum of 5 and 4?
(Security Question)*

Send Application 

Helpful Information

Accepted conditions

The following medical conditions are automatically covered and you do not need to tell us about them, as long as you:
  1. have no other pre-existing medical conditions which are not listed below
  2. are not awaiting surgery for the condition
  3. have been fully discharged from any post-operative follow-up

Special Terms

In addition to any Medical Condition on the list above, you may be automatically accepted for cover, provided You do not have more than ONE of the following Medical Conditions or ANY other Pre-existing Medical Condition.


Arthritis (Juvenile, Osteoarthritis, Rheumatoid or Psoriatic Arthritis, Reiter's Syndrome, Rheumatism, Synovial Inflammation):
 • There must have been NO hospital admissions within the last 12 months.
 • Must NOT affect the back more than any other area of the body.
 • No more than 2 medications.
 • No mobility aids (other than walking stick or frame).
 • Must NOT be awaiting surgery.
 • Must have NO lung problems.

Asthma (Wheezing):
 • There must have been NO hospital admissions EVER.
 • Must have been diagnosed prior to age 50.
 • Must be controlled with no more than 2 medications (NO nebuliser, No home oxygen).
 • Must have been a non-smoker for at least 12 months.
 • Must be able to walk 200 yards on the flat without becoming short of breath.

Diabetes Mellitus (Sugar Diabetes):
 • Type 2 (Non-Insulin-Dependent Diabetes Mellitus) only.
 • Controlled by diet alone or by no more than 1 medication (no insulin).
 • There must have been NO hospital admissions or diabetic complications ever.
 • Must have been a non-smoker for at least 12 months.

Down's Syndrome:
 • There must be NO associated conditions or complications (e.g. congenital heart disease, epilepsy, gastrointestinal abnormalities)

Hypercholesterolaemia (High Cholesterol):
 • No more than 1 medication.
 • Must NOT be the inherited form.
 • Must have been a non-smoker for at least 12 months.

Hypertension (High Blood Pressure, White Coat Syndrome, Controlled Blood Pressure):
 • No more than 2 medications.
 • There must have been no change in treatment within last 6 months.
 • Must have been a non-smoker for at least 12 months.

Hypotension (Low Blood Pressure):
 • Must NOT be associated with any underlying condition.

Osteoporosis (Osteopaenia, Fragile Bones):
 • There must have been NO vertebral (backbone) fractures

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