New Contract App

Insured Name

If Insured is a corporation or organized as, enter here. Or, enter individual name. This information is only for identification for new account on submission and may be generalized.

Insurance Agent Name (sending form)

First NameLast Name

Email of Insurance Agent

agent@insurancebroker.ca

Upload Signed Merit Insurance Premium Finance Contract

May be signed as Buyer, PAP and Continuous, for each applicable person

Payment Method

Bank Name or Bank Number

Example: RBC 003

Routing Number

Bank Account Number

Secure Transmit Card Information

Secure Storage of Card Information and Updating Card Information. The Amount to be Paid by Card will be determined by Documentation provided. This cost is only for transmission, storage and updating of Card information.

Free for the first 1 Year then, $1.00 CAD for each year

Card Holder Email

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

OPTIONAL: Upload Copy of Void Cheque or PAP Authorization

Name on Card, if different than account name

Postal Code of customer

Customer Email

example@example.com

Customer Tel Number

Area CodePhone Number

OPTIONAL: Upload Copy of Card, if you have it (both sides please)

Please enter email that the customer will be sending Etransfer from, if known

Name of Bank for Online Bank Payments, if known

Please describe anticipated form of payment

Inception Payment/ Down Payment

Other

Proposed Date for Withdrawal

if none selected, it will be within 2 business days of date of receipt

Dec Page, if available

Upload terms and dec as applicable

Special Request or Notes

Merit Payment Plan (New Contract Application)

Banking Information

Credit or Debit Card Information

Coupon- Etransfer or Online Bank Payment

Coupon- Broker Pay, Cheques, Other