Name of Applicant

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Trading Name

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FCA Number

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Telephone Number

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Email Address

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Website

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Legal Structure

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Are you directly authorised or part of a network
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Products sold

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Current providers of long term

income protection insurance

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Current providers of Accident, Sickness and Unemployment insurance

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Name of product sourcing platforms used

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Name of CRM software used

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Transaction Model

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Access Needed For

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Email commission statements

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Email premium defaults and cancellation

notifications

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