Agent Application Spam protection, skip this field Business name Full business address Commission address (if different) (optional) Postcode Email Fax (optional) Web (optional) Company Reg. number Service provider details Country Bank name Postcode Sort code IBAN number Account name Type (please tick) Indemnity Non indemnity Reduce earnings period (2yrs) † Payment frequency Weekly Monthly Title Mr Mrs Miss Ms Other (please specify) If Other please specify (optional) Forename(s) Surname National insurance number Position in firm Postcode Title (optional) Mr Mrs Miss Ms Other (please specify) If Other please specify (optional) Forename(s) (optional) Surname (optional) National insurance number (optional) Position in firm (optional) Postcode (optional) If different to the people above, please give the following information for each of the firm’s business Representative: first name, surname, business address and postcode, date of birth, national insurance number and their business phone, fax and mobile numbers and email address. (optional) You can give us these details by return with this application form or you can email them to [email protected] on a spread-sheet or complete section 10 ‘additional information’. Please give full details if you or your firm’s directors, partners or principals are now or have ever been linked with any agencies associated (optional) (a) Has the firm, or any of its directors, partners or principals(including any business that they have been involved in previously) had a receiver or administrator appointed, entered voluntary or compulsory liquidation, been declared bankrupt or been the subject of a bankruptcy petition or entered into an arrangement with creditors? Yes No (b) Are any of the matters in (a) pending in respect of the firm, or any of its directors, partners or principals(including businesses that they have been involved with in the last 2 years)? Yes No (c) Has the firm, or any of its directors, partners or principals been the subject of a court judgement for outstanding debts which, if enforced, would result in them becoming insolvent? Yes No (d) Has the firm, or any of its directors, partners or principals ever had an application for agency refused, or had such an application suspended, withdrawn or granted subject to conditions Yes No (e) Has the firm, or any of its directors, partners or principals, been convicted or the subject of investigation relating to fraud, dishonesty, bribery or been the subject of investigation or disciplinary action by a professional body? Yes No (f) Have any of the directors, partners or principals been convicted of a criminal offence (other than for motoring)? Yes No If you have answered Yes to any of the questions above, please give full details (optional) I/We accept terms and conditions. I/We Reject the terms and conditions Additional Information (optional) Full name Position (optional)