New Customer Form

Please submit the details below to register as a new customer with Insight Workplace Health

Company Name

Company Registration Number

Trading Name

VAT Number

Company Address (the address which will be on the invoice)

Company Postcode

URL

Company Industry

If 'Word of mouth' please specify

Please enter the accounts department contact / person who will receive invoices

Contact Name

Contact Number

Please provide a secondary generic finance email

Preferred payment method

Pay by Invoice (link embedded in invoice)

Pay by Direct Debit

Other

(payment terms: from 14 days)

(payment due on receipt of invoice)

(default terms are: payment up-front)

Portal Contact Name

Portal Information (Insight uses a secure portal to process medical reports), this will be our main point of contact (usually HR or Health and Safety)

Portal Contact Number

Portal Contact Email

By completing the checkbox I hereby acknowledge that all details provided are true and correct to the best of my knowledge and I agree to the terms & conditions. View terms of use

Name

Job Title

Your Signature

New Customer Form

Portal Information (Insight uses a secure portal to process medical reports), this will be our main point of contact (usually HR or Health and Safety)

Please note: portal fees are applicable for each login, these will be renewed every 12 months.