Please complete the short form below
Items marked with * indicate required fields.
Firm Name *
Firm Type * Sole TraderLimited CompanyLimited Liability PartnershipNon-Limited Partnership
Firm Status * Directly AuthorisedAppointed Representative
FCA Number *
Registered Address *
Post Code *
Please tick if the trading address the same as the registered office.
Date Established *
Telephone Number *
Number of Advisors *
Please detail the individuals responsible for the following aspects of the agency.
Primary Contact Name *
Primary Contact Email *
Primary Contact Phone No *
Firm Administrator Name
Firm Administrator Email
Firm Administrator Phone No
Retail Mediation *
Retail Mediation Email *
Retail Mediation Phone No *
Compliance Phone No
Sales Email Address
Sales Phone No
Please choose which of the following products you would like access to:
Residential Home Insurance
Tenants Contents Insurance
Let Property Insurance
Home Emergency Insurance
Short Term Income Protection (ASU)
Mortgage Payment Protection (ASU)
Motor GAP Insurance (RTI & RTF)
Motor Contract Hire GAP
Personal Accident Insurance
Please provide details of the account you wish to have your commission paid into.
Bank Name *
Account Name *
Bank Address *
Bank Post Code *
Sort Code *
Account Number *
Please tick to confirm the following statements:
Neither you, as an individual, or any director or partner has ever had your registration or enrolment of any professional or statutory body denied or terminated?
You or your firm have never had a similar agency with any insurer/ provider denied/ terminated?
You or any of your fellow directors or partners have never been subject to disciplinary proceedings by a regulatory or professional body?
You or any of your fellow directors or partners have never been involved with any business that has gone into receivership or liquidation?
If you unable to tick any of the disclosures above or you would like to provide any supporting comments please detail them in the box below.
Form completed by:
Phone Number *
Please tick if you would like someone to telephone you about this application.
6 + 0 = ? Please prove that you are human by solving the equation *
FRN Number: 517325
Registered in England & Wales
Company Number: 06741789
© Cavere Insurance 2016
2 Horizon Court
Audax Close, Clifton Moor
+44(0) 1904 476090
Denison Till Company Secretaries Ltd