AXA Connect

eServe Registration form

 

  • By completing the form below you are registering for an eServe Broker Administrator profile. Broker Administrator profiles are available for a small number of individuals within a brokerage responsible for creating and maintaining eServe profiles for their brokerage and for their associated agency numbers.

    (Please note that fields marked with an asterisk * are mandatory fields)

    Please tick yes below to confirm that you would like to register for a Broker Administrator profile.

             

    Full name:*

    Email address:* (Please provide your personal unique work email address)


    Telephone number:* (Please enter full number without spaces)

    Unique Agency Number(s): 
    (Please provide a full list of the UAN(s) you would like to have access to below separated by a comma. You will be able to grant Broker users with your organisation access to these UAN(s)).
      
     
    Organisation postcode:*

    Organisation trading name:*

    Organisation Company name:* (This may be different to your trading name if you are a member of a broker group) 

     
    Companies House number:


    FCA Number:*


     
     

    You can register up to 10 additional Broker profile users now. You are only required to fill in the fields for the number of eServe users with a Broker profile that you wish to register. Both full name and email address are mandatory fields in order to register an additional user. Please provide a unique email address for each user, as a generic email address or inbox cannot be set for multiple users.

    Broker profile user 1
    Full name:

    Email address:
    Broker profile user 2
    Full name:

    Email address:
    Broker profile user 3
    Full name:

    Email address:
    Broker profile user 4
    Full name:

    Email address:
    Broker profile user 5
    Full name:

    Email address:
    Broker profile user 6
    Full name:

    Email address:
    Broker profile user 7
    Full name:

    Email address:
    Broker profile user 8
    Full name:

    Email address:
    Broker profile user 9
    Full name:

    Email address:
    Broker profile user 10
    Full name:

    Email address: