Application Form

If you would like to register your details and become an On Insurance partner
please fill in our application form below.

Your details

Name *

Full company or business name *

No. of years established *

Full business address and postcode *

Registered address (if different)

Telephone number *

Fax number

Email address *

Website address

Business status *

(If Limited Company, enter registered number)

Please provide the following information for all principals, partners or directors

Name and title *

Position in firm *

Home address and postcode *

Date of birth *

National insurance number *

Please provide details of any relevant experience or qualifications

Authorisation

Are you FCA authorised *

Yes

FCA registration no

If you are exempt from FCA authorisation through membership of a designated professional body or regulation of a different body, please give details here

Name of body

Registration number

Date of registration

Date of termination

Been the subject of a receiving order?

Yes

Entered into an arrangement with creditors?

Yes

Been a director of a company which has been wound up other than for purposes of amalgamation or reconstruction?

Yes

Been the subject of a court judgement for any outstanding debts?

Yes

Had an application refused by any Insurance Company?

Yes

Been convicted of a criminal offence (other than motoring)?

Yes

If you have answered 'Yes' to any of the above, please provide details below

Send Enquiry

Application Form

Application Process

Your details

Please provide the following information for all principals, partners or directors

Authorisation

If you are exempt from FCA authorisation through membership of a designated professional body or regulation of a different body, please give details here