Agency Application

Company Details

Company Name:

Contact Title:

Full Name:

Job Title:

Telephone Number:

Email Address:

Do you want to add this person as a system user as well:
Yes No

Registered Postcode:

Registered Address:

Town:

FCA authorisation number:

Which broker software do you currently use:

Are you a member of any Network Group:
Yes No

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

Title:

Full Name:

Email Address:

Do you want to add this person as a system user as well:
Yes No

Head Office

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

Office Details

Office Name:

Registered Postcode:

Registered Address:

Town:

Telephone Number:

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

Users

Name	Email	Update / Delete

Company Name:

Title:

Full Name:

Telephone :

Email Address:

Additional offices

Professional Indemnity Cover

Insurer:

Limit of Indemnity:

Excess:

Have you ever made a claim under your PI policy:
Yes No

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

Yes No

DPA Statement

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