Helpline: 0845 466 5533

Broker Registration

Please fill in the following form carefully. Fields marked with a * are mandatory.

If you have any questions you can contact us

Upon submission of the form, we will carry out relevant credit checks and if approved, an Underwriter will contact you directly using the eMail and telephone details below to organise a meeting to sign agreements and provide username and password login details

You will receive an automated response to this registration to the eMail address specified below within 4 hours

About You
First Name *
Last Name *
eMail Address *
Confirm eMail Address *
Telephone Direct *

About Your Company

Company Name *

Building Name/Number *

Postcode *

Fill in Address

Address Line 1 *

Address Line 2

Town / City *

Switchboard *

Fax Number

Is this a Limited Company? *

YES NO

Existing Allianz Cornhill Broker *

YES NO

Lloyds Broker *

YES NO

FSA Approved *

YES NO

Products *

Estimated Premium Income (in £s) *

Where did you find out about Duet? *

Please answer one of the following questions *

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