Citybond : New Agency Application Form

	Home \| About Us \| Contact Us \| Careers \| Agent Login \| Press Office \| Industry Events

	There are no schemes existing


	Documentation

		Summary of Changes
		Summary of Cover
		Policy Wordings
	Information

		CTI Regulation 2009
		EHIC

Please complete the Agency Details Form and then Click on the Send Application button below.
Fields marked by * are mandatory.

Agency Details

Agency Name in full*

Trading Name
(If different from above)

Trading Address*

Type of Business*

Limited Company
Partnership
Sole Trader

Company Registration No

Registered Address

(if different to above)

Head Office Address

(if different to above)

No of Branches

Telephone No.*

Fax No.

Email Address*
(Your agency confirmation
will be emailed to this address)

Retype Email Address*

Website Address

Daily Contact Name*

Job Title

Professional Indemnity Insurance details ...
If available please provide details of your professional indemnity insurance policy
Professional Indemnity insurance
Regulatory Compliance details ...
If available, please supply
Contact Name (Compliance)
Job Title
Tick if you are registered with the FSA for insurance sales
FSA Authorisation No

Type of Agency*

Member of Trade Association

ABTA
ABTA exams have been
completed.
ATOL
AITO
TTA
IATA
BIBA

Other – please specify

Which schemes would you sell?
(tick all that apply)

Single Trip Insurance
Annual Multi-Trip Insurance
Winter Sports
Long Stay Insurance
Backpacker/ Gap Year

Net premium paid in last 12 months

Name of current broker/insurer
you are selling

Terms of Business Agreement

Please click here to read the Terms of Business Agreement (TOBA)

Tick to confirm you have read and accepted the TOBA

Where did you hear about Citybond?