BROKER APPLICATION FORM
Submitter First and Last Name:
*
Submitter Email:
*
Brokerage Name:
*
Website:
Broker Principal(s) - Titles
Rows
Name
Title
1.
2.
3.
4.
Broker Principal(s):
Address:
*
City:
*
Province:
*
Postal Code:
*
Accounting Contact Name:
*
Accounting Email Address:
*
example@example.com
Cancellations/Arrears Contact Name:
*
Cancellations/Arrears Email Address:
*
example@example.com
Broker Management System Used:
BROKER PROFILE
Phone:
*
Years in Business:
*
No. of Offices:
No. of Employees:
Gross Written Premium (previous year):
Rows
Gross Written Premium
% Commercial
% Personal
Gross Written Premium (previous year):
Enter amount in $
Annual Financed Premiums:
BROKER LICENSE
Broker License Number:
*
Provinces registered in:
*
SPECIALTY LINES OR PROGRAMS
Fill out the table if applicable
Rows
Industry/Program
Gross Written Premium
1.
2.
3.
4.
5.
ADDITIONAL INFORMATION REQUIRED
Please attach a copy of a void cheque for funding:
*
Browse Files
Cancel
of
Please upload a list of (i) Insurance companies and MGAs, and (ii) Users to be added to online quoting by uploading files required OR inputting the information directly within form (see proceeding question):
Browse Files
Cancel
of
Please complete the list of Insurance companies and MGAs:
Please provide contact information for users to be added to online quoting:
BROKER REPRESENTATION AND WARRANTIES
Please review the Broker Representation and Warranties terms outlined in the PDF attached below. Return back to this form to sign and submit your application.
Legal Broker Name:
*
Signature:
*
Signature:
Title:
*
Print Name:
*
Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Preview PDF
Submit
Should be Empty: