WEBroker Application Form
Please click here to download and print the Voyager WEBroker Application Form, or complete the online version below.
Company Name:
Address of main office:
Postcode:
Telephone:
Fax:
E-mail:
Website Address:
Date business established:
Type of organisation (e.g. Sole Trader/Patnership/Limited Co.):
If a Limited Company, please advise:
Company Registration Number:
Authorised Share Capital:
Paid Up Share Capital:
Are you associated with another company? yes no
If YES, please details:
Address(es) of additional offices (if any)
1st additional office address:
Postcode:
2nd additional office address:
Postcode:
Total number of Full Time staff:
Total number of Part Time staff:
Please provide the name of your Bankers:
Please provide the address of your Bankers:
Has any application to any professional or regulatory body been refused, declined, cancelled or withdrawn? yes no
If YES, please give reasons:
Are you members of the GISC? yes no
If YES, please give Membership No:
Have you received your FSA “Minded to Approve”? yes no
If YES, please give reference number:
Have you received your FSA “Scope of Permission”? yes no
If YES, please give reference number:
Name of Director(s) / Principal(s)
Name:
Home Address:
Years at this address:
Date of Birth:
Qualifications:
Years in Insurance:
Name:
Home Address:
Years at this address:
Date of Birth:
Qualifications:
Years in Insurance:
Name:
Home Address:
Years at this address:
Date of Birth:
Qualifications:
Years in Insurance:
Has any Director or Principal ever:  
a) Had an insurance agency cancelled or refused? yes no
b) Been adjudged bankrupt or subject to a receiving order or County Court Judgement? yes no
c) Been convicted of any criminal offence (not treated as spent under the Rehabilitation of Offenders Act 1974) other than motoring convictions? yes no
If YES to any of the above, please provide details:
Please provide details of your Professional Indemnity insurance:
Name of Insurer:
Limit of Indemnity:
Expiry date:
Excess:
Please list the major travel insurance agencies that you use and the related annual gross premium income:
1. 
2. 
3. 
4. 
Total:
Please confirm your office’s main method of access to the Internet:
Dial-up: yes no
Broadband: yes no
Contact person dealing with this application:
Name:
Position:
Email Address:
Declaration: By clicking on the 'submit application' button below I confirm that all the information contained within this Agency Application is correct to the best of my knowledge.
Voyager Insurance Services Ltd is authorised and regulated by the Financial Services Authority (Firm reference no. 305814)
Copyright © 2008 Voyager Insurance Services Ltd.