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New Agency Application

Please complete the Agency Details Form and then Click on the Send Application button below.
Fields marked by * 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 FSA for insurance sales

FSA 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
andaccepted the TOBA
Where did you hear about Citybond?
Word Verification Type the characters you see in the picture below.

Citybond Holdings Plc is registered in England at 109 Elmers End Road, Beckenham, Kent BR3 4SY. Reg no. 1478367. Authorised & Regulated by the Financial Services Authority.