Online Travel Insurance Product, Travel Insurance Service Agency Application Worldwide

Europesure Agency Application

Please provide the following information
Name of Organization :
Trading Address1 :
Address 2 :
Contact Name (s) :
Telephone:
Fax :
E-mail :
Website Address :
Principal Trading Activities :
Date Business Established :
If less than 2 years please give previous relevant experience below and two business references :
Reference 1 :
Reference Address 1 :
Reference 2 :
Reference Address 2 :
Are you regulated under any statutory or professional body ?	Yes No
If yes, please give us details :
Do you have professional indemnity insurance ?	Yes No
If yes, please give us name of insurance company :
Expiry date of policy :
Policy number :
Have you ever had an agency declined or terminated ?	Yes No
Please give the name of two other agencies that you hold :	1. 2.
I CERTIFY THAT THE INFORMATION GIVEN ABOVE IS CORRECT