Please complete the Agency Details Form and then click on the
Send Application button below.
Fields marked * are mandatory.
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Agency Details |
Agency Name in full* |
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Trading Name (if different from above) |
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Trading Address* |
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Postcode* |
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Type of Business* |
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Company Registration No |
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Registered Address (if different from above) |
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Postcode |
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Head Office Address (if different from above) |
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Postcode |
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No of Branches |
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Telephone No* |
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Fax No |
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Email Address* (Your agency confirmation will be emailed to this address) |
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Retype Email Address* |
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Website Address |
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Daily Contact Name |
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Job Title |
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Professional Indemnity Insurance details |
If available please provide details of your professional indemnity insurance policy. |
Professional Indemnity Insurance* |
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Regulatory Compliance details |
If available, please supply |
Contact Name (Compliance) |
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Job Title |
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Are you registered in your country to sell insurance? |
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FCA Authorisation No |
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Are you registered to sell insurance to non-UK residents* |
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Type of Agency* |
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Member of Trade Association* |
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Other - please specify |
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Which schemes would you sell? |
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Net premium paid in last 12 months* |
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Name of current broker / insurer you are selling |
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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* |
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Where did you hear about Citybond?* |
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Send Application
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