Panel form

Which business area does this request relate to *

Please select mortgages general insurance mortgages & general insurance

Type of request *

Please select new contact (new to Halifax) new/additional payment route amend intermediary details

Do you require an online CD

Please select yes no

Section 1 - intermediary details

Select type of intermediary *

Please select mortgage broker estate agent accountant builder solicitor

Name of network/mortgage club/ payment route(s) * †

If you are registered as an appointed representative please ensure that the required payment route has been authorised by your principal

Intermediary/contact name *

Company name *

Address line 1 *

Address line 2

Address line 3

Post town *

Post code *

Telephone number *

 

Fax number

Mobile number

Email address *

Name of business development manager (if applicable)

Section 2 - mortgage regulation permissions

Status

Please select directly authorised appointed representative

Company FSA number *

FSA permissions - advise

Please select yes no

FSA permissions - lifetime

Please select yes no

Section 3 - insurance regulation

Status

Please select directly authorised appointed representative

Company FSA number *

FSA permissions fully authorised to conclude

advise arrange introduce

† In certain cases we may need your bank details to complete our processes. If this is the case we will contact you via telephone or email.