Agency Application

Company Details


Accounts contact

Please enter account contact details. This should be the contact who will receive monthly statements for your business, alternatively if you wish these to be sent to a group please enter the group email address


Head Office

This is the main office of your business, any additional offices can be added under the Additional Offices section

Office Details

Enter the details of all staff you wish to have access to the system for this office.


Additional offices
Professional Indemnity Cover

Statements

Regulatory statement

In connection with this application, Exance Limited will use the information supplied on this form, together with any information subsequently supplied by you in connection with the operation of the agency (Terms of Business) agreement, to carry out initial and subsequent credit checks with credit reference agencies which will retain a record of those searches.

Exance Ltd may also undertake Bankruptcy searches on the same basis in relation to all individuals named on the application form. In addition, this information together with other information relating to this application and any subsequent agency appointment may be disclosed to an agency and may be shared with insurers and associations for the purposes of assessing further applications.

Exance Ltd will also undertake an initial and subsequent Sanctions search in relation to both the Entity and all Directors named on the application form.

I/We declare that the information given on this application is true and complete and I/We declare that this information shall be the basis of our Terms of Business Agreement with Exance Ltd

I/We undertake to advise Exance Ltd immediately of any changes to the enclosed information. This undertaking is to be a continuing obligation on my/our part throughout the terms of the agency appointment.Yes No

DPA Statement

I/We consent to the disclosure and use of the information given in this application in accordance with Privacy notice.