Agency Application Form

Sales Contact

Has a member of our sales team contacted you?

Yes No

If Yes:

Which of our sales executives were you dealing with?

Approximately when were you speaking with them last?

Company Details

Insurance Details

Net annual insurance turnover *

Projected annual Insurance turnover *

Period (Years) *

Current Renewal Date *

Type of Business (%)

Late Bookings (less than 4 weeks)

Tailor-made

Flight Only

Cruise

Package

Business Travel

Weekend Break

Other

Business Split (%)

Europe

Worldwide (Excl USA)

Worldwide (Incl USA)

Type of Policy (%)

Single Trip

Annual

Backpack / Longstay

Client Age Band (%)

Under 66

70-80

66-69

81+

Declaration/Confirmation

Please double check the entries you have made above, once you are happy please check the box, you will then be able to submit your application.

I hereby confirm the above to be a true, accurate and valid assessment of my Insurance needs.

Please enter the text you see on the right