slide1

New Agency Application Form

Please complete the Agency Details Form and then click on the Submit button below.

Fields marked by * are mandatory.

Agency Details
Select the areas of Insurance you are interested in*

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
Website Address
Daily Contact Name
Job Title
Daily Contact Email Address * *
Professional Indemnity Insurance details
If available please provide details of your professional indemnity insurance policy.
Professional Indemnity Insurance
Professional Indemnity Insurer *
Renewal Date * dd/mm/yyyy
Regulatory Compliance details
Compliance Contact Name
Job Title
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.
*
FCA Authorisation No *
Accounts details
Accounts Contact Name
Accounts Email Address
Are you a member of any Broker Network?
If yes then please provide details

Where did you hear about DOA?
Please enter any additional information here:
 

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*

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