Agency Application Form
Company Name
Trading Name (if different from above)
Registered Address
Telephone Number
Fax 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 FSA Firm Reference Number 
Are you able to hold client money?
Professional Indemnity Insurer 
Limit of Indemnity 
Renewal Date