Broker Account Application

Please complete the form below if you wish to apply for a Broker Account with U-SURE.
Name / Trading Name:
Address:
Address of additional offices
(if any)
Telephone:
Fax:
Email:
Website:
Date business was establised:
FSA registration number:
Type of company:
Partnership
Sole Trader
LTD (please provide company registration number)  
PLC
Other (please specify)  
Are you associated with another company? Yes     No
If so please provide details:
Have you traded under a previous title? Yes     No
If so please provide details:
Please provide the name and address of your bankers:
Your prefered method of payment: - Cheque
U-SURE Insurance Services Ltd, P.O Box 3000, Newport. NP18 1WY

- BACS

- Direct Bank Credit
HSBC - sort code 40-34-27 – account number 52035723
Contact person dealing with application:
Contact person for account queries:
All monies falling due at month end is to be paid to U-SURE by the 28th of the following month. A Statement of Account will be generated by us to you. By signing this agreement you agree to the above terms.
Signed:
(By entering your name it will act as your online signature)
Position: