Application Form

Your details

Name *

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Full company or business name *

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No. of years established *

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Full business address and postcode *

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Registered address (if different)

Telephone number *

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Fax number

Email address *

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Website address

Business status *

(If Limited Company, enter registered number)

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

Name and title *

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Position in firm *

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Home address and postcode *

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Date of birth *

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National insurance number *

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Please provide details of any relevant experience or qualifications

Authorisation

Are you FCA authorised *

Yes

No

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

No

Entered into an arrangement with creditors?

Yes

No

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

Yes

No

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

Yes

No

Had an application refused by any Insurance Company?

Yes

No

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

Yes

No

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