Application for Terms of Business Loading… Brokerage Contact Details Required fields must be filled up. *Required Fields Name of Brokerage*: Telephone No. of Brokerage*: Email of Brokerage*: Address of Brokerage*: Where brokerage company is registered*: Give details of relevant Licences or authorisations held (if any): Bank account details for commission payments*: Principal Contact Details Principal Name*: Principal Maiden Name: Mobile phone of Principal*: Email address of Principal*: Address of Principal*: Country of Birth*: Place of Birth*: Principal ID Details*: Date of Birth of Principal*: Main types of business written*: Brokerage Consultant Complete for all consultants that require a sub-account for commission calculation and application inputpurposes, including Principal if appropriate. Please enclose/upload Identification and Proof of Residential Address for all individuals named, as well as the applicant. We will not be able to accept business without this. Consultant Name*: Consultant Maiden Name: Consultant Mobile Phone*: Email address of Consultant*: AFIBL Consultant Number: Address of Consultant*: Country of Birth*: Place of Birth*: Consultant ID details*: Date of Birth of Consultant*: Add more Brokerage Consultant Supporting Documents Allowed file types are docs, pdf, xls. Max file size 5MB. Files that will not meet requirements will not be uploaded. Please accept this as my application for Terms of Business with Life Administration Services Limited ("LAS"). I confirm that all the information contained herein is true and accurate, and I undertake to inform LAS should any of this information change in the future.