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New Agency Application

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*

Company Registration No
Registered Address
(if different from above)
Head Office Address
(if different from 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
Are you registered in your
country to sell insurance?

FCA Authorisation No
Are you registered to sell
insurance to non-UK residents*

If Yes, please can you confirm by providing the license by email
Type of Agency*
Member of Trade Association*  
Other - please specify
Which schemes would you sell?
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
andaccepted the TOBA*
Where did you hear about Citybond?*

Citybond Holdings Ltd., 109 Elmers End Road, Beckenham, Kent BR3 4SY. Registered in Cardiff No. 1478367. Authorised & Regulated by the Financial Conduct Authority.