Broker Application


Complete the form below and click on the button to begin the broker registration process.


Your information will be validated, and then you will be directed to a page where you can download the Broker Application form, which you should complete and fax (0870 766 8392) or email to agency@leisureinsure.co.uk.


Leisureinsure will complete the registration process and send you your documentation.


Your Online Access will be activated once the Application Form has been received and accepted and the TOBA issued. Therefore please ensure that your application is returned as soon as possible.


Broker Details


Brokerage Name
Address Line 1
Address Line 2
City
Postcode
Phone
Email
FSA Regulatory No
Name of applicant