Broker Agency Application

Agency Details

Select the areas of Insurance you are interested in

Travel

Personal Accident

Financial Professions

Excess Liabilities

Commercial

Contact Name:

Agency Name in full:

Trading Name (if different from above):

Type of business:

Limited Company

Partnership

Sole Trader

Registered Address (if different from above):

Number of Branches:

Telephone Number:

Website Address:

Daily Contact Name:

Job Title:

Daily Contact Email:

If available please provide details of your professional indemnity insurance policy.

Professional Indemnity Insurer:

Renewal Date:

Professional Indemnity Insurance:

Compliance Contact Name:

Compliance Email Address:

Are you fully authorised with the FCA for insurance sales:

If No, please continue to complete this application, however we will need to contact you with regards to further verification details.

Yes

FCA Authorisation No:

Accounts Contact Name:

Accounts Email Address:

Are you a member of any Broker Network?

If yes, then please provide details.

Yes

Which software platform(s) do you use? E.g. Acturis

Where did you hear about DOA?

Please enter any additional information here:

Please CLICK HERE to read the Terms of Business Agreement (TOBA).
Please ensure you print off a copy of this TOBA for your records as this will form the basis of your agency agreement with us.

I confirm that I have read and accepted the TOBA