Please complete agency application form

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


Director/Partner Information

Name

Business Income Details


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

£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£

Business Contact Details


Accounts Contacts

Name

Personal Lines Renewal Contacts

Name

Commercial Renewal Contacts

Name

System User Requirements (Name, Telephone and Email Address)

Name

Professional Indemnity Cover

£
£

if yes please provide details of cost and circumstances

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.