Distributor Registration


Distributor
Company Name: *
Trading Name 1: *
Do you have more than one trading name? Yes  No
Trading Name 2:
Trading Name 3:
Trading Name 4:
Trading Name 5:
NZBN:
Contact:
Principal First Name:
Principal Last Name:
Address 1:
Address 2:
Suburb:
Region:
Postcode:
Postal Address:
(if different from above)
Phone:
Fax:
Mobile:
Email:
Website Address:

Help us to understand your business a little better
Has any insurer ever refused you cover or not invited renewal? Yes  No
If Yes, please provide full details and circumstances;
Do you currently refer or discuss insurance related questions with your customers? Yes  No
Years in Business
Number of vehicles:
Sub contractors:
What type of Contents do you usually Carry?
Household Personal Effects
Commercial/Industrial (ie; Office, Factory relocations)
Freight Transporter
Importer/Exporter
Details of General Freight carried:
(ie; Clothing, Machinery, Chemicals)
Any other information that you think might help us understand your business (ie What Type of Insurances your Business currently holds where we could assist related to CARTS):
* Indicates a mandatory field.