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.