Agency Application Form
General
Company Name
Trading Name (if different from above)
Trading Status
Registered Address
Company Registration Number, if applicable
Full names and dates of birth of all Directors, Principles and Partners
Name Date of Birth
Telephone Number
Email Address
Website
Name & Contact Details for the individual responsible for insurance mediation.
Name & Contact Details for the person responsible for compliance issues.
Number of offices
Branch Addresses (If applicable)
Please confirm your FCA Firm Reference Number 
Are you able to hold client money?
Professional Indemnity
Professional Indemnity Insurer 
Limit of Indemnity 
Renewal Date 
Policy Number
Have any Director, Principle or Partner, whether in the United Kingdom or elsewhere:
a) Been the subject of any civil proceedings, arbitration or litigation, including proceedings that have led to or may lead to a County Court Judgement (CCJ) or other judgement debts?
b) Been the subject of any bankruptcy proceedings?
c) Entered into a deed of arrangement or an individual voluntary arrangement (or in Scotland a trust deed) or other agreement in favour of your creditors, or are you doing so?
d) Been involved with any company which went into receivership or administration?
e) Been refused, restricted in, or had suspended, the right to carry on any trade, business or profession for which specific licence, authorisation, registration, membership or other permission is required?
f) Been disqualified by a court from acting as a director of a company or from acting in a management capacity or conducting the affairs of any company, partnership or unincorporated association?
g) Ever been convicted of, or charged but not yet tried for, a criminal conviction?