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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:

Marketing
If you’re happy to receive occasional information about our products, services and offers by email please tick here:
Don’t worry, we keep marketing emails to a minimum and you can easily unsubscribe at any time.


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