Account Modification
This may be used to send request of account modification by Broker
Agent Name
First Name
Last Name
Insurance Brokerage or Merit Broker Code
*
Insurance Agent Email
*
agent@insurancebroker.ca
Merit Account Number
*
This is only for existing accounts
Insured Name
*
For identification purposes
Request
Change or Add Info for Insured Address
Modify Policy Number
Proposal to Change Pay Date
Cancel Policy (please upload copy of cancellation)
Update Banking or Payment Details (please upload copy of banking info)
Change Payment Method
Notify of Credit
Request Payment Confirmation or Account Information
Seeking Special Assistance
Change Address for
Mailing
Telephone
Email
New Mailing Address
Street Address
Street Address Line 2
City
Province
Postal Code
Provide Amount
Change Payment Method To
Coupon/ Payment Reminder/ Customer Push Payment/ Etransfer/ Online Payments
PAP
Credit Card or Debit Card Payments
Provide Insured Telephone Number
-
Area Code
Phone Number
Switch Insured to Coupon Payments (Etransfer, Cheques, Online Payments, etc.)
New Bank Name and Bank Number
New Bank Routing Number
New Bank Account Number
Provide Insured Email Address
example@example.com
Any Change of Name on Account
New Name for Account Holder
Provide Proposed Date
-
Month
-
Day
Year
Date
Basis for Change of Payment Date
Any further information to communicate?
For a Credit be effective on an Insured Account, the Monies must be forwarded to Merit. Once received it will be credited to the account.
Sending Funds by Mail or ICS
Would like Merit to Withdraw Specific Amount from Broker Account for Credit
Confirm Amount to Withdraw
Name of Insurer or MGA
Old Policy Number
New Policy Number
Broker Bank Name and Bank Number
Broker Bank Routing Number
Broker Bank Account Number
Email Validator
*
Upload Any Relevant Dec Page, Cancellation, PAP authorization, Void Cheque, Contract or Document
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of
Provide Revised Information or Updated Details or Request
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