New Contract App

Merit Payment Plan (New Contract Application)

Easy Transmit Secure Upload
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
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Payment Method
Banking Information

For PAP
Bank Name or Bank Number
Example: RBC 003
Routing Number
Bank Account Number
Credit or Debit Card Information

Upload Copy of Void Cheque or PAP Authorization

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Name on Card, if different than account name
Postal Code of customer
Customer Email
example@example.com
Customer Tel Number

Area CodePhone Number
Upload Copy of Card, if you have it (both sides please)(optional)

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Coupon- Etransfer or Online Bank Payment
Please enter email that the customer will be sending Etransfer from, if known
Name of Bank for Online Bank Payments, if known
Coupon- Broker Pay, Cheques, Other
Please describe anticipated form of payment
Inception Payment/ Down Payment

Broker Collected Down Payment in FullMerit to Collect Down Payment in FullCredit or Debit Card applied for MeritPay Now Down PaymentCredit Card applied for MeritPay Down Payment DeferralTransfer Funds from Prior Account (in whole or part)Merit to Collect Down Pay Plus Missed PaymentsCustomer sending Down Payment to Merit by Etransfer or otherBroker sending Down Payment to Merit (broker may retain it)Merit to Collect specific amount as specified in Special Request or Notes to be ProvidedOther
Proposed Date for Withdrawal

MonthDayYear
if none selected, it will be within 2 business days of date of receipt
Dec Page, if available

Upload terms and dec as applicable
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Special Request or Notes
Should be Empty:

Merit Payment Plan (New Contract Application)