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Agency Application
Company Details
Company Name:
Please enter the contact within your company who is authorised to act on the behalf of the business in relation to all Agency matters
Contact Title:
Select...
Mr
Mrs
Miss
Ms
Doctor
Admiral
Air Chief Marshal
Air Commodore
Air Marshal
Air Vice Marshal
Airman
Baron
Baroness
Bombardier
Brigadier
Brother
Canon
Captain
Cardinal
Chief
Colonel
Commander
Commodore
Corporal
Councillor
Count
Countess
Dame
Dean
Estate Of
Executor(s) of
Father
Field Marshal
Flight Lieutenant
Flight Sergeant
General
Group Captain
Gunner
Honourable
Judge
Lady
Lance Bombardier
Lance Corporal
Lieutenant
Lieutenant Colonel
Lieutenant Commander
Lieutenant General
Lord
Major
Major General
Master
Master Sergeant
Mother
Mr Justice
Prince
Private
Professor
Provost
Rabbi
Rear Admiral
Regimental Sergeant Major
Reverend
Right Reverend
Sergeant
Sheikh
Sir
Sister
Squadron Leader
Staff Sergeant
The Duke of
The Earl of
The Honourable Lady
The Honourable Miss
The Honourable Mrs
The Honourable Sir
The Marquess of
The Most Reverend
The Right Honourable
The Venerable
Trustees Of
Very Reverend
Viscount
Viscountess
Warrant Officer 1
Warrant Officer 2
Wing Commander
Unstated
Contact Name:
Telephone (contact):
Email (contact):
Do you want to add this person as a system user as well:
Yes
No
This must be the Registered address of the business, not the Correspondence address
Registered Postcode:
Registered Address:
Town:
FCA authorisation number:
Are you a member of any Network Group:
Yes
No
Which network do you belong to:
Select...
Ataraxia
Broker Network
Brokerbility
Cobra Network
Hedron
Pure Networks
Willis Towers Watson
Una Alliance
Ten Network
Movo
PIB Group
GRP Group
Other network name:
Which broker software do you currently use:
Select...
Acturis
Applied
Durell
SSP
Open GI
Other broker software name:
What is your company's estimated GWP:
£
Director/Partner
Please enter all Directors/Partners for your business
Title:
Select...
Mr
Mrs
Miss
Ms
Doctor
Admiral
Air Chief Marshal
Air Commodore
Air Marshal
Air Vice Marshal
Airman
Baron
Baroness
Bombardier
Brigadier
Brother
Canon
Captain
Cardinal
Chief
Colonel
Commander
Commodore
Corporal
Councillor
Count
Countess
Dame
Dean
Estate Of
Executor(s) of
Father
Field Marshal
Flight Lieutenant
Flight Sergeant
General
Group Captain
Gunner
Honourable
Judge
Lady
Lance Bombardier
Lance Corporal
Lieutenant
Lieutenant Colonel
Lieutenant Commander
Lieutenant General
Lord
Major
Major General
Master
Master Sergeant
Mother
Mr Justice
Prince
Private
Professor
Provost
Rabbi
Rear Admiral
Regimental Sergeant Major
Reverend
Right Reverend
Sergeant
Sheikh
Sir
Sister
Squadron Leader
Staff Sergeant
The Duke of
The Earl of
The Honourable Lady
The Honourable Miss
The Honourable Mrs
The Honourable Sir
The Marquess of
The Most Reverend
The Right Honourable
The Venerable
Trustees Of
Very Reverend
Viscount
Viscountess
Warrant Officer 1
Warrant Officer 2
Wing Commander
Unstated
Name:
Email address:
Do you want to add this person as a system user as well
Yes
No
Delete
Accounts contact
Please enter account contact details. This should be the contact who will receive monthly statements for your business, alternatively if you wish these to be sent to a group please enter the group email address
Title:
Select...
Mr
Mrs
Miss
Ms
Doctor
Admiral
Air Chief Marshal
Air Commodore
Air Marshal
Air Vice Marshal
Airman
Baron
Baroness
Bombardier
Brigadier
Brother
Canon
Captain
Cardinal
Chief
Colonel
Commander
Commodore
Corporal
Councillor
Count
Countess
Dame
Dean
Estate Of
Executor(s) of
Father
Field Marshal
Flight Lieutenant
Flight Sergeant
General
Group Captain
Gunner
Honourable
Judge
Lady
Lance Bombardier
Lance Corporal
Lieutenant
Lieutenant Colonel
Lieutenant Commander
Lieutenant General
Lord
Major
Major General
Master
Master Sergeant
Mother
Mr Justice
Prince
Private
Professor
Provost
Rabbi
Rear Admiral
Regimental Sergeant Major
Reverend
Right Reverend
Sergeant
Sheikh
Sir
Sister
Squadron Leader
Staff Sergeant
The Duke of
The Earl of
The Honourable Lady
The Honourable Miss
The Honourable Mrs
The Honourable Sir
The Marquess of
The Most Reverend
The Right Honourable
The Venerable
Trustees Of
Very Reverend
Viscount
Viscountess
Warrant Officer 1
Warrant Officer 2
Wing Commander
Unstated
Name:
Email address:
Do you want to add this person as a system user as well
Yes
No
Head Office
This is the main office of your business, any additional offices can be added under the Additional Offices section
Office Details
Office Name:
Postcode:
Address:
Town:
Telephone (Office):
This will be the person that renewals will be sent to. If you require the renewals to be sent to a group, please enter the group email address.
Personal Lines Renewal Contact
Title:
Select...
Mr
Mrs
Miss
Ms
Doctor
Admiral
Air Chief Marshal
Air Commodore
Air Marshal
Air Vice Marshal
Airman
Baron
Baroness
Bombardier
Brigadier
Brother
Canon
Captain
Cardinal
Chief
Colonel
Commander
Commodore
Corporal
Councillor
Count
Countess
Dame
Dean
Estate Of
Executor(s) of
Father
Field Marshal
Flight Lieutenant
Flight Sergeant
General
Group Captain
Gunner
Honourable
Judge
Lady
Lance Bombardier
Lance Corporal
Lieutenant
Lieutenant Colonel
Lieutenant Commander
Lieutenant General
Lord
Major
Major General
Master
Master Sergeant
Mother
Mr Justice
Prince
Private
Professor
Provost
Rabbi
Rear Admiral
Regimental Sergeant Major
Reverend
Right Reverend
Sergeant
Sheikh
Sir
Sister
Squadron Leader
Staff Sergeant
The Duke of
The Earl of
The Honourable Lady
The Honourable Miss
The Honourable Mrs
The Honourable Sir
The Marquess of
The Most Reverend
The Right Honourable
The Venerable
Trustees Of
Very Reverend
Viscount
Viscountess
Warrant Officer 1
Warrant Officer 2
Wing Commander
Unstated
Name:
Email address:
Do you want to add this person as a system user as well:
Yes
No
Commercial Lines Renewal Contact
Title:
Select...
Mr
Mrs
Miss
Ms
Doctor
Admiral
Air Chief Marshal
Air Commodore
Air Marshal
Air Vice Marshal
Airman
Baron
Baroness
Bombardier
Brigadier
Brother
Canon
Captain
Cardinal
Chief
Colonel
Commander
Commodore
Corporal
Councillor
Count
Countess
Dame
Dean
Estate Of
Executor(s) of
Father
Field Marshal
Flight Lieutenant
Flight Sergeant
General
Group Captain
Gunner
Honourable
Judge
Lady
Lance Bombardier
Lance Corporal
Lieutenant
Lieutenant Colonel
Lieutenant Commander
Lieutenant General
Lord
Major
Major General
Master
Master Sergeant
Mother
Mr Justice
Prince
Private
Professor
Provost
Rabbi
Rear Admiral
Regimental Sergeant Major
Reverend
Right Reverend
Sergeant
Sheikh
Sir
Sister
Squadron Leader
Staff Sergeant
The Duke of
The Earl of
The Honourable Lady
The Honourable Miss
The Honourable Mrs
The Honourable Sir
The Marquess of
The Most Reverend
The Right Honourable
The Venerable
Trustees Of
Very Reverend
Viscount
Viscountess
Warrant Officer 1
Warrant Officer 2
Wing Commander
Unstated
Name:
Email address:
Do you want to add this person as a system user as well:
Yes
No
Enter the details of all staff you wish to have access to the system for this office.
Users
Name
Email
Update / Delete
Additional offices
Office name:
Office Details
Office Name:
Postcode:
Address:
Town:
Telephone (Office):
This will be the person that renewals will be sent to. If you require the renewals to be sent to a group, please enter the group email address.
Personal Lines Renewal Contact
Title:
Select...
Mr
Mrs
Miss
Ms
Doctor
Admiral
Air Chief Marshal
Air Commodore
Air Marshal
Air Vice Marshal
Airman
Baron
Baroness
Bombardier
Brigadier
Brother
Canon
Captain
Cardinal
Chief
Colonel
Commander
Commodore
Corporal
Councillor
Count
Countess
Dame
Dean
Estate Of
Executor(s) of
Father
Field Marshal
Flight Lieutenant
Flight Sergeant
General
Group Captain
Gunner
Honourable
Judge
Lady
Lance Bombardier
Lance Corporal
Lieutenant
Lieutenant Colonel
Lieutenant Commander
Lieutenant General
Lord
Major
Major General
Master
Master Sergeant
Mother
Mr Justice
Prince
Private
Professor
Provost
Rabbi
Rear Admiral
Regimental Sergeant Major
Reverend
Right Reverend
Sergeant
Sheikh
Sir
Sister
Squadron Leader
Staff Sergeant
The Duke of
The Earl of
The Honourable Lady
The Honourable Miss
The Honourable Mrs
The Honourable Sir
The Marquess of
The Most Reverend
The Right Honourable
The Venerable
Trustees Of
Very Reverend
Viscount
Viscountess
Warrant Officer 1
Warrant Officer 2
Wing Commander
Unstated
Name:
Email address:
Do you want to add this person as a system user as well:
Yes
No
Commercial Lines Renewal Contact
Title:
Select...
Mr
Mrs
Miss
Ms
Doctor
Admiral
Air Chief Marshal
Air Commodore
Air Marshal
Air Vice Marshal
Airman
Baron
Baroness
Bombardier
Brigadier
Brother
Canon
Captain
Cardinal
Chief
Colonel
Commander
Commodore
Corporal
Councillor
Count
Countess
Dame
Dean
Estate Of
Executor(s) of
Father
Field Marshal
Flight Lieutenant
Flight Sergeant
General
Group Captain
Gunner
Honourable
Judge
Lady
Lance Bombardier
Lance Corporal
Lieutenant
Lieutenant Colonel
Lieutenant Commander
Lieutenant General
Lord
Major
Major General
Master
Master Sergeant
Mother
Mr Justice
Prince
Private
Professor
Provost
Rabbi
Rear Admiral
Regimental Sergeant Major
Reverend
Right Reverend
Sergeant
Sheikh
Sir
Sister
Squadron Leader
Staff Sergeant
The Duke of
The Earl of
The Honourable Lady
The Honourable Miss
The Honourable Mrs
The Honourable Sir
The Marquess of
The Most Reverend
The Right Honourable
The Venerable
Trustees Of
Very Reverend
Viscount
Viscountess
Warrant Officer 1
Warrant Officer 2
Wing Commander
Unstated
Name:
Email address:
Do you want to add this person as a system user as well:
Yes
No
Enter the details of all staff you wish to have access to the system for this office.
Users
Name
Email
Update / Delete
Delete Office
Professional Indemnity Cover
Insurer:
Renewal date:
Limit of Indemnity:
£
Excess:
£
Have you ever made a claim under your PI policy:
Yes
No
Please provide details of costs and circumstances:
Statements
Regulatory statement
In connection with this application, Jensten Underwriting (SME) Ltd and Jensten Underwriting (Commercial) 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 credit checks with credit reference agencies which will retain a record of those searches.
Jensten Underwriting (SME) Ltd and Jensten Underwriting (Commercial) Ltd may also undertake Bankruptcy searches on the same basis in relation to all 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 associations for the purposes of assessing further applications.
Jensten Underwriting (SME) Ltd and Jensten Underwriting (Commercial) Ltd will also undertake an initial and subsequent Sanctions search in relation to both the Entity and all Directors named on the application form.
I/We declare that the information given on this application is true and complete and I/We declare that this information shall be the basis of our Terms of Business Agreement with Jensten Underwriting (SME) Ltd and Jensten Underwriting (Commercial) Ltd
I/We undertake to advise Jensten Underwriting (SME) Ltd and Jensten Underwriting (Commercial) Ltd immediately of any changes to the enclosed information. This undertaking is to be a continuing obligation on my/our part throughout the terms of the agency appointment.
Yes
No
DPA Statement
I/We consent to the disclosure and use of the information given in this application in accordance with Privacy notice.
Privacy Notice & Information | Jensten Underwriting (SME) (jenstenunderwriting.co.uk).
Submit Application
User details
Title:
Select...
Mr
Mrs
Miss
Ms
Doctor
Admiral
Air Chief Marshal
Air Commodore
Air Marshal
Air Vice Marshal
Airman
Baron
Baroness
Bombardier
Brigadier
Brother
Canon
Captain
Cardinal
Chief
Colonel
Commander
Commodore
Corporal
Councillor
Count
Countess
Dame
Dean
Estate Of
Executor(s) of
Father
Field Marshal
Flight Lieutenant
Flight Sergeant
General
Group Captain
Gunner
Honourable
Judge
Lady
Lance Bombardier
Lance Corporal
Lieutenant
Lieutenant Colonel
Lieutenant Commander
Lieutenant General
Lord
Major
Major General
Master
Master Sergeant
Mother
Mr Justice
Prince
Private
Professor
Provost
Rabbi
Rear Admiral
Regimental Sergeant Major
Reverend
Right Reverend
Sergeant
Sheikh
Sir
Sister
Squadron Leader
Staff Sergeant
The Duke of
The Earl of
The Honourable Lady
The Honourable Miss
The Honourable Mrs
The Honourable Sir
The Marquess of
The Most Reverend
The Right Honourable
The Venerable
Trustees Of
Very Reverend
Viscount
Viscountess
Warrant Officer 1
Warrant Officer 2
Wing Commander
Unstated
Name:
Telephone:
Email address:
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