Please complete and submit the form
below to apply to be a Lumley Jacobs Affiliate online
or
click here to download a PDF version of the application
form to be returned to Lumley Jacobs by fax or post.
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| Section 1A Key contact details |
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Fields marked with an asterisk must
be completed
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| Title |
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| Other title |
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 First
name |
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| Surname |
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| Job title: |
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| Company
name |
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| Postcode |
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| Enter building name or number |
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| Telephone |
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| Mobile |
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| Email
to which all general correspondence documentation will be sent |
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| Section 1B Company Head Office details - if
different from above |
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| Company address |
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| Town |
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| County |
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| Postcode |
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| Telephone |
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| Fax |
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| Email
to which all order/purchase documentation will be sent |
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| Customer
facing website address |
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| If you have additional branches that you wish to
include please see Section 4. |
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| The
following information will help us administer your account |
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| Section 2 Bank details |
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| Please enter the details of the account where you wish
your referral fees to be paid. |
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| Name of bank |
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| Name of account |
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| Account number |
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| Sort code |
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| Section 3 Additional company information |
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| Are you VAT registered? |
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| If yes, please give VAT number |
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| Please do not fill this in if you are not sure of your
VAT status - as we are not able to retroactively amend VAT transacted business.
Note: If this section is not completed we will assume you are not VAT
registered. |
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| Are you FSA authorised? |
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| Are you BIBA registered? |
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| Please indicate the number of employees in your company |
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| Is the company part of a network? |
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| If yes, please give the name of the broker network |
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| Your broker network may be eligible for additional
referral fees. |
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| Please can you indicate percentage split between
personal/commercial lines? |
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| Please indicate which products you are interested in |
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| Section 4 Additional branches |
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| If you have additional branches or franchises that you
would like to include please give details on a separate sheet including; branch
name, address, telephone number and email to which all order/purchase
documentation should be sent.
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| If you would like us to provide specific sales reports for
additional branches please tick the box.
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| Section 5 Please give the contact details for the
following departments |
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| Section 5A Finance Department
- key contact |
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| First name |
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| Surname |
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| Job title |
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| Telephone |
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| Mobile |
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| Email |
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Address (if different
from head office) |
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| Town |
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| County |
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| Postcode |
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| Section 5B Sales and Marketing Department - key
contact |
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| Please indicate whether you require a branded (white
labelled) version of the sales literature |
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| First name |
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| Surname |
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| Job title |
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| Telephone |
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| Mobile |
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| Email |
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Address (if different
from head office) |
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| Town |
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| County |
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| Postcode |
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| Section 5C IT Department - key contact |
| 5C(i) Customer facing website contact |
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| First name |
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| Surname |
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| Job title |
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| Telephone |
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| Mobile |
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| Email |
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Address (if different
from head office) |
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| Town |
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| County |
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| Postcode |
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| 5C(ii) Back end internal system contact (if
different from above - 5C(i)) |
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| First name |
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| Surname |
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| Job title |
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| Telephone |
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| Mobile |
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| Email |
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Address (if different
from head office) |
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| Town |
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| County |
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| Postcode |
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| 5C(iii) Branded (White labelled) internal systems |
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| If your company requires a branded (white labelled)
order/purchase system, please fill out the questions below. |
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| Do you want to white label the Lumley Jacobs order/purchase
system? |
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| For more information on white labelling, please visit
www.LumleyJacobsAffiliates.com or call 0844 848 7770. |
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| Do your telesales (or sales) staff have internet access? |
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| Information relating to IT should be emailed to
it@lumleyjacobs.com |
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