Register - Emergence Insurance

Brokerage registration

Brokerage website*

Brokerage legal entity name*

Brokerage trading name*

Brokerage branch*

Primary Brokerage contact

The primary brokerage contact will be used by Emergence to liaise with your brokerage. It will not be used for communications with clients.

First Name*

Last Name*

Phone*

Email*

Brokerage contacts

Email for notices*

This is the email address that will be used to send Renewal notices and Claims notices. Notices should not be linked to an individual broker. We recommend a Group email such as 'info@...'.

Email for finance/premium payments*

This is the email address that will be used for notification of finance/premium payments. Notices should not be linked to an individual broker. We recommend a Group email such as 'finance@...'.

Address

Licensing

Licensing*

AFSL / FSP holder

Authorised representative

AFSL / FSP number*

Authorised representative number*

Cluster Group*

Cluster group / other*

Broker Group (if applicable)*

Cluster group / other*

Personal Cyber Express

Do you want to enable Personal Cyber Express for your Brokerage?*

Yes, enable Personal Cyber Express for my Brokerage

No, don't enable Personal Cyber Express for my Brokerage

Email for personal cyber notifications*

The email for personal cyber notifications will be used to copy your brokerage on all communications sent directly to the client e.g. issue of the policy document and renewal expiry notices. It will also be used to send you the monthly report of Personal Cyber policies bound during the last month through your brokerage.

Broker fee (ex GST)*

Telephone number for Personal Cyber*

The telephone number will be displayed on the Personal Cyber generated emails and documents.

Broker logo*

Drop files here or

Accepted file types: jpg, png, Max. file size: 3 MB, Max. files: 1.

Terms and conditions

I have read and agree to the Terms and Conditions of Trade*

I have read and agree to the Terms and Conditions of Trade

Name

This field is for validation purposes and should be left unchanged.

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