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Get an agency online form

To apply for an agency with Victor Insurance, please complete this form. You must be an authorised person to complete this form on behalf of the applicant.

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Legal status *
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Please provide the full branch address(es) here. *
Date business established *
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Contact telephone number * Contact mobile number *
Are you a member of any network or broker group? *
If yes, please indicate which:
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Are you an Appointed Representative of an FCA authorised firm? *
Are you registered with the Information Commissioner's Office? *
Are you authorised by the FCA for credit broking? *
Do you hold client money permissions? *
Please confirm the type of bank account you operate *
Please confirm the approx. size of your firm in GWP *

Breakdown of your activities

Do you have any specialisms &/or specifically targeted sectors?
Who are your key insurer relationships?
Do you hold any delegated authorities or schemes? *
Do you have any Appointed Representatives? *
Do you place business on behalf of other insurance brokers? *
What broker software system do you use? *

Attach File *

The completion and submission of this application is not binding upon either party.

Any appointment is conditional upon the applicant having accepted the Terms of Business Agreement which will be made available prior to appointment and upon acceptance of the application by Victor Insurance.

DECLARATION

The Contact making this application is authorised to complete and submit this form on behalf of the applicant and bind the applicant to the terms and conditions of the Victor Insurance Terms of Business.

The applicant, business or any of its directors or partners have not:

  • been subject to a CCJ or been adjudged bankrupt, subject to a receiving order, been wound up, been subject to winding up proceedings, entered into an agreement with creditors or been involved in any business that has gone into liquidation nor is any such matter pending
  • been subject to or are not currently subject to disciplinary proceedings instituted by any regulator, professional body or government body or agency;
  • been the subject of any criminal proceedings or convicted of any criminal offence
  • been a defendant in any civil proceedings connected with an allegation of fraud or dishonesty had any agency or application for agency with any Insurer refused, revoked or terminated
  • had an agency/application refused, declined, terminated or withdrawn

The applicant has in place adequate procedures and controls to prevent bribery and corruption.

The applicant will pay due regard to, and co-operate in respect of the observance of, any applicable international, economic, financial or trade sanctions legislation.

After investigation I/we confirm that the information given in this application is to the best of my/our knowledge true, complete and correct.