This form has to be completed and submitted as an online application. We cannot accept handwritten or scanned forms.
For information on how we use your personal data please refer to our Privacy Notice.
Producer / Broker Details
Email address doesn't match
Clients US Business Information
Client Information
Vehicle Details
Driver Details - Driver 1
Driver Details - Driver 2
Coverage Requirements
Additional Information
We’d like to tell you about our products or services that may interest you. Please tick if you would like to hear about these by:
You can opt out of marketing communications at any time by contacting us at uk.unsubscribe@ajg.com
Quantum Underwriting Solutions is a trading name of Arthur J. Gallagher Insurance Brokers Ltd. We are the data controller of any personal information you provide to us or personal information that has been provided to us by a third party. We collect and process information about you in order to arrange insurance policies and to process claims. Your information is also used for business purposes such as fraud prevention and detection and financial management. This may involve sharing your information with third parties such as insurers, reinsurers, other brokers, claims handlers, loss adjusters, credit reference agencies, service providers, professional advisors, our regulators, police and government agencies or fraud prevention agencies.
We may record telephone calls to help us monitor and improve the service we provide. For further information on how your information is used and your rights in relation to your information please see our Privacy Notice. If you are providing personal data of another individual to us, you must tell them you are providing their information to us and show them a copy of this notice.
