Organization

1. Legal name of organization
2. Principal place of business and address
3. Postal address (if different)
4. Communication details: Web site address Email address Telephone number Fax number
5. Type of organization
   • Publicly held company
   • Privately held corporation
   • Partnership
   • Sole proprietor
   • Other (please explain)
6. Parent company (if applicable)
7. Please list province(s)/state(s) in which you hold a license and nature of these licence(s)
8. Has the organization, or any of its current stockholders, directors, partners, proprietors or principal officers, ever been convicted of a criminal offense?
   • yes
   • no

   Please provide details

Nature of Business

1. Please check the box which best reflects the Applicant's main business activity
   • Retail Insurance Broker
   • Wholesale Broker
   • Other (please explain)
2. What is the approximate annual gross total premium volume of your organization for the past 3 years?

The Organization's Professional Indemnity Insurance

1. Do you purchase Professional Indemnity (E&O) Insurance?
   • yes
   • no
2. If yes please state: Carrier Limit of Liability Deductible

Accounting Department

1. Do you keep segregated funds or in trust accounts for insurance premiums?
2. Please provide contact info for your accounting department: Name Phone number

Your information

Name:

Position: