Policyfast | Agency Application

Successful brokers use Policyfast

Please complete agency application form

Agency Application

Apply for an agency

To register an account with Policyfast, please complete our simple online application form. Before you register we recommend you read through our terms and conditions to ensure you fully understand the rules and regulations of your account. Please complete the form as accurately as possible.

Company Details

Broker name

Telephone (general)

Fax (general)

Email (general)

Website URL

Contact

Telephone (contact)

Email (contact)

Date business established

Type of firm

Company registration number

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Postcode

FCA authorisation number

Are you associated with any other firm?

Yes No

Please give details

Are you authorised to hold client money?

Yes No

Do you have an Insurer Trust Account?

Yes No

You have answered NO to holding clients money and having an insurer trust account.
Do you have any form of trust account for holding clients monies? If so please give details.

Yes No

Please give details

Are you a member of any Network Group?

Yes No

Please advise which software house you presently use

Are you engaged in any sub-broking activity?

Yes No

Please give details

Director/Partner Information

Name	Age

Business Income Details

Please indicate approximate GWP for all types of business, if not applicable please enter £0.

Commercial Vehicle

Courier

Combined Motor Trade

Motor Trade Road Risks

Taxi

Minibus

GIT

Property Owners

Truck

Fleet

Retail

Office

Liability

Caravan

Commercial Combined

Contractors All Risks

Estimated Total GWP

Business Contact Details

Accounts Contacts

Name	Telephone	Email

Personal Lines Renewal Contacts

Name	Telephone	Email

Commercial Renewal Contacts

Name	Telephone	Email

System User Requirements (Name, Telephone and Email Address)

Name	Telephone	Email

Professional Indemnity Cover

Insurer

Renewal date (e.g. 20/11/2024)

Limit of indemnity

Excess

Have you ever made a claim under your PI policy?
if yes please provide details of cost and circumstances

Yes No

Please give details

Consumer credit licence number

Declaration

In connection with this application Policyfast Ltd will use the information supplied on this form, together with any information subsequently supplied by you in connection with the operation of the agency (Terms of Business) agreement, to carry out initial and subsequent regular credit checks with credit reference agencies which will retain a record of those searches and Policyfast Ltd may also undertake bankruptcy searches on the same basis in relation to all of the individuals named on the application form. In addition, this information together with other information relating to this application and any subsequent agency appointment may be disclosed to an agency and may be shared with insurers and trade associations for the purposes of assessing further applications.

I/we declare that the information given on this application is true and complete and I/we agree that this application shall be the basis of our Terms of Business Agreement with Policyfast Ltd. I/we undertake to advise Policyfast Ltd immediately of any changes to the enclosed information. This undertaking is to be a continuing obligation on my/our part throughout the term of any agency appointment.

I/we consent to the disclosure and use of the information given in this application in accordance with the data protection notice given above.

I Agree