Blink Agency Application Form

Main Details

Firm Name*

Firm Type*

Please upload a copy of your accounts for due diligence purposes*

Max. file size: 10 MB.

Firm Status*

Please answer the following questions relating to your regulatory principal firm:

Principal Firm Name*

Prinicipal Firm FCA Number*

Principal Firm Address*

Street 1 Street 2 Town/City County Post Code

Principal Firm Contact Name*

Consent*

I have the permission of my principal firm to apply for this agency with Cavere Insurance

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Your FCA Number*

Your Registered Address*

Street 1 Street 2 Town/City County Post Code

Is your trading address the same as your registered address?*

No (please specify below)
Yes

Your Trading Address*

Street 1 Street 2 Town/City County Post Code

Your Company Number

Your Telephone Number*

Number of Advisors*

Website Address

Agency Contacts

Please detail the individuals responsible for the following aspects of the agency.

Primary Contact Name*

Primary Contact Email*

Primary Contact Phone No*

Firm Administrator Name

Firm Administrator Email

Firm Administrator Phone No

Retail Distribution*

Retail Distribution Email*

Retail Distribution Phone No*

Firm Compliance

Compliance Email

Compliance Phone No

Product Sales

Sales Email Address

Sales Phone No

Finance Contact*

Commission Statements Email Address*

Product Selection

Please choose which of the following products you would like access to:

Product Access

Residential Home Insurance

Bank Details

Please provide details of the account you wish to have your commission paid into.

Bank Name*

Account Name*

Bank Address*

Street 1 Street 2 Town/City County Post Code

Sort Code*

Account Number*

Disclosures

Please tick to confirm the following statements:

Disclosure 1

Neither you, as an individual, or any director or partner has ever had your registration or enrolment of any professional or statutory body denied or terminated?

Disclosure 2

You or your firm have never had a similar agency with any insurer/ provider denied/ terminated?

Disclosure 3

You or any of your fellow directors or partners have never been subject to disciplinary proceedings by a regulatory or professional body?

Disclosure 4

You or any of your fellow directors or partners have never been involved with any business that has gone into receivership or liquidation?

Further information on disclosures

If you unable to tick any of the disclosures above or you would like to provide any supporting comments please detail them in the box below.

Form completed by:

Your Name*

First Last

Your Email*

Enter Email Confirm Email

Your Phone Number*

Telephone Communication Authorisation

Tick if you would like someone to telephone you about this application.

Processing method

By default we will handle your application by email and issue the TOBA for e-signature. If you would prefer to receive and sign this via post, please select this here:

Digitally
By Post

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