New Registration of Broker/Intermediary



If you submit these details, we will email you your user details. Having a password will give you access to our Quoting facility and our current Wordings. Please feel free to call if you have any queries.
Name of Business & FSRA Licence No.  
Broker/Intermediary Code
Postal address  
Email address  
State  
Contact Name  
Contact phone number
Staff numbers/names
Are you a current NIBA member? YesNo
Current book of Business
Value of the Book
Individual Travel
Corporate Travel
Group Personal Accident
Expatriate Medical
Actual value of current portfolio through us
Are you a IBNA broker/intermediary? YesNo
Are you a AUST broker/intermediary? YesNo
Are you a STEADFAST broker/intermediary? YesNo
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