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First Name *

Surname *

Trading or Business Name *

No/Name

Business Address *

Business Address Line 2

City

Postcode

Telephone Number *

Fax Number

Website Address

Email Address

Accounts Email Address

How did you hear about Commercial Express?

Have you previously held a Commercial Express Agency?

Have any persons listed above, or has any company in which they held a management position, been involved in liquidation, receivership, bankruptcy, dissolved, high court writ, voluntary wind up orders been struck off or is any similar procedure pending?

Have any persons listed above been convicted of any criminal offences, other than Motoring offences?

Have any persons listed above had provision of bond or fidelity guarantee in the past declined, terminated or restricted?

Have any persons listed above had an insurance agency or insurance agency application declined, terminate or restricted?

Do any of the persons listed above have an agreement, express or implied, with any other entity which prevents or restricts them from holding an insurance agency. Whether generally or with Commercial Express?

Do you offer any sub-broking facilities? If yes, please submit a full agent list to agency@commercialexpress.co.uk

Regulatory Information

FCA Number

Do you have FCA permission to hold client money?

Is the company a member of any broker network?

If yes, please provide details:

Please provide details of your professional indemnity insurance.

Name of Insured

Policy Number

Renewal Date

Limit of Indemnity

By submitting this registration form, you must indicate your explicit consent to receiving telephone and email marketing messages from us. Please explicitly opt in or should you choose to, please opt out by choosing one of the options below before submitting:

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It’s easy to register with us; we’ll get in contact and see how we can help.

Regulatory Information

Please provide details of your professional indemnity insurance.