Agency Application Form

Thank you for your interest in applying for an agency with GB Underwriting.  If you are an FCA authorised intermediary and based in the UK, please fully complete the online form below.  Once your application has been submitted, you will receive a confirmation email.  We will then endeavour to process your application as soon as possible.  Please feel free to contact us if you have any questions about the application process.

Company name:

Trading name(s) if different:

Company status:

Company Address:

Tel:

Email:

Website address:

Contact name:

Position:

FCA Firm Reference Number:

Current PI Certificate:

Date business started trading:

Are you authorised to hold client money?YesNo

Are you permitted to arrange general insurance business?YesNo

Have you ever been refused or deferred the granting of an agency?YesNo

Have you ever been subject to regulatory censure, discipline, or investigation?YesNo

Has any Director ever been convicted of a criminal offence (other than a driving offense), or declared bankrupt?YesNo

Has the Company ever been in administration or been subject to a court judgment?YesNo

Please provide details of Directors/Partners/Owners

Name Date of Birth Qualifications Insurance Experience (Years)

Number of staff involved in insurance activities:

Do you have sub agents and/or Appointed Representatives advising and arranging insurance on your behalf?YesNo

Please provide a summary of your insurance activities:

Please provide details of the source of the business which you generate:

Please provide details of the type of insurance business generated:

Your total gross written premium:

Commercial:

Personal Lines:

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Services for UK based businesses only. GB Underwriting Limited is an independent intermediary and authorised and regulated by the Financial Conduct Authority and is entered on the FCA register under reference 304281. Registered Address: 75 Springfield Road, Chelmsford, CM2 6JB All content ©2017 GB Underwriting. Site design by KURTZ