New Agency Application

If you are not already registered then complete the New Agency Application form below and start to take advantage of streamlining your process.

Broker Information
Company Details
Trading Name
Address
  Postcode      
Telephone number
Fax number
Email address
  Company Registration Number      
  Type of Organisation      
Names of Directors (if Ltd Co)
Please provide a list of current agencies
1 2
3 4
5 6
  Are you a HSBC/Marsh guaranteed broker?      
Compliance Details
  Are you a fully authorised member of the FSA?      
  Please provide your FSA Number      
Please state your Professional Indemnity limit
Who is your PI policy held with?
When does your PI policy expire?  
Business Details
Please provide your gross premium income
Please provide a split in your premium income between Tradesman
 %  
Retail
 %  
Office
 %  
Commercial Combined
 %  
Personal Lines
 %  
Vans and Fleet
 %  
Personal Accident
 %  
Other
 %  
         
What system do you use i.e. OpenGI, SSP, CDL
Do you accept sub-broked business or act as a Wholesale Broker?
Any other comments
Bank Details
Name of Bank
Address
Postcode
Bank Sort Code
Account Number
Declaration
Please provide your name
What is your position in the company
  What is your email address      
Has any director, Partner, Proprietor or Manager personally or by association:
  Had any agency with any insurer refused, cancelled or restricted for any reason other than lack of support?      
  Been subject to any criminal offence (other than motoring)?      
  Been involved in liquidation, receivership, bankruptcy, high court writ, voluntary wind up order or is any similar procedure pending?      
  Been subject to a County Court Judgement or Order?      
  Been subject to any disciplinary proceeding by any professional body?      
  If any answer is ‘yes’ then please provide details      
We hereby make application to become an agent of Moorhouse Xbroker.

We declare that the information given in this application is accurate and complete and we agree that this application is the basis for the working relationship between ourselves and Moorhouse Xbroker.

We understand that in the event that any of the information contained in this application is not complete or accurate then our Terms of Business Agreement may be terminated by Moorhouse Xbroker at its sole discretion.

By submitting this application we hereby consent to Moorhouse Xbroker conducting a credit check on the Applicant and/or any of the persons named.
Documents
Please note that the application requires the following documents before it can be processed. To save time, we will accept them in electronic format attached to this application. Can you attach the following:
  Copy of your last FULL audited accounts      
  If your latest audited accounts are over 9 months old then please send a copy of your latest management accounts      
  Copy of your current/in-force PI Schedule/Certificate?      
  Any other documents?      
  If you cannot send the above documents electronically then please forward them without delay to:       Agency Department,
Moorhouse Xbroker,
Barclay House,
Pontygwindy Road,
Caerphilly,
CF83 2WJ
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Moorhouse Xbroker is a trading title of Moorhouse Group Ltd who is Authorised and regulated by the Financial Services Authority Reg No 308035.
© Moorhouse Group Ltd 2007