Non Standard Insurance, Mid Net Worth Insurance

The Applicant

Trading Name: (if not a limited company, please state whether a partnership, sole trader or other)

Name and title of person responsible for agency:

Head/Registered office address inc postcode:

Address Line 1
Address Line 2
Address Line 3
Address Line 4
Postcode

Contact information:

Office		Direct (if applicable)
Fax		Email
Website		Co. Reg. No

Name and title of person responsible for Accounts :

Accounts correspondence address inc postcode: (if different from above)

Address Line 1
Address Line 2
Address Line 3
Address Line 4
Postcode

Accounts contact information:

Office		Direct (if applicable)
Fax		Email

Please state the firm's FSA Firm Reference Number:

Expected number of quote requests to be referred/submitted to Plum Underwriting over next year?
Expected GPI of applicable business to be referred to Plum Underwriting over next year?

The Firm

Number of Branches

if more than one branch, please complete the fields below if neccessary:

Branch No	Address Including Postcode	Main Contact	Telephone
1
2
3
4
5

Information required for online quotation facility set-up - “The Broker Centre”

Username:

Your username will be confirmed to you by email once your agency has been approved. The username can be shared by all members of staff.
If you have more than one branch, we will issue one username per branch.

Password:

Please provide at least a 6 character password:

Where did you hear about Plum Underwriting?

Oak

HSBC Labyrinth

HSBC

Other

Who referred you to obtain an agency from Plum Underwriting? (if applicable) :

Information

Any additional information:

Declaration

I/we declare that all the information given in this application form is, to the best of my/our knowledge, true and complete.
I/we agree that the completed form and any additional information I/we provide will be the basis of the agreement between me/us and
Plum Underwriting Ltd should it be granted.

I confirm that I am authorised to complete and submit this Agency Application form on behalf of my company.

Full name	Postion Held	Date