Agency Client Updated Details Form

Please take a moment to complete the form below so we have all the practical information we need to continue working with you.

Updated Agency Information

Registered Business Name(Required)

Trading Name

(if different to registered name)

Registered Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Registration Number (Incorporation Number)(Required)

VAT Number (Company Tax Number)(Required)

Insurance Requirements(Required)

The following insurances for Assigned Workers will be maintained: (a) Professional Indemnity Insurance, with coverage up to five (5) million €; (b) Public Liability Insurance, with coverage up to five (5) million €; and (c) Employer Liability Insurance, with coverage up to five (5) million € or a local equivalent where required by law. Please confirm accordingly if more or less is required.

Notes

Please indicate requirements if change required.

Agency Contact Information

Primary Contact(Required)

First Last

Primary Contact Office Address

(if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title(Required)

Email(Required)

Contact Number(Required)

Invoice and Payment Contact Information

Contact name for invoice processing and payments(Required)

First Last

Email(Required)

Contact Number(Required)

Email to Receive Invoices (if different from above)

Self-Billing or Invoices Required?(Required)

Invoice Address

(if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Information Provided By(Required)

First Last

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Date(Required)

Who We Help

Why Workwell

Resources

Partnerships

Agency Client Updated Details Form

Updated Agency Information

Agency Contact Information

Invoice and Payment Contact Information