Submit a Referral

To ensure we are able to contact your customers easily and quickly please ensure all fields are completed accurately. Please note referrals are dealt with on a priority basis and we apologise if you experience any delays.

We ideally ask that you make the referral 2-3 weeks prior to the expected inception/renewal date to avoid the last minute panic of needing to arrange cover under time constraint pressures. This allows us the best opportunity to provide your client with the best advice and best possible premium/cover.

Please ensure that you have already completed the Registration Form if this is your first referral.

Submit a Referral

Your Firm's FCA Number *

Your Full Name *

Your Firm's Business Name *

Your Email Address *

Your Mobile Number *

If you have a preference, please specify which adviser you would like to process the referral. Leave blank if you have no preference

Customer Cover Details

Policy Due Date *

Current insurer

Target premium

If other Insurance - please specify

Customer Contact Details

Please tick here to confirm you have the relevant permission from your customer to pass their data on to Towergate for the purpose of providing a General or Commercial Insurance quotation? *

Yes, I have the relevant permission to pass on client data.

Customer Name *

Main Contact Number *

Email Address *

1st line of Address *

2nd line of Address

Town *

County *

Postcode *

Notes/ comments