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0333 207 0506

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*  
Type of Business*  
Company Registration No
Registered Address
(if different from above)
Head Office Address
(if different from above)
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 in your
country to sell insurance?
FCA Authorisation No
Are you registered to sell
insurance to non-UK residents*
If Yes, please can you confirm by providing the license by email
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?*

Send Application 

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
Please click here to read the Special Terms

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

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.

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

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

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