USERNAME
PASSWORD
Organization
Legal name of organization
Principal place of business and address
Postal address (if different)
Communication details:
Web site address
Email address
Telephone number
Fax number
Type of organization
Publicly held company
Privately held corporation
Partnership
Sole proprietor
Other
(please explain)
Parent company (if applicable)
Please list province(s)/state(s) in which you hold a license and nature of these licence(s)
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
Please check the box which best reflects the Applicant's main business activity
Retail Insurance Broker
Wholesale Broker
Other
(please explain)
What is the approximate annual gross total premium volume of your organization for the past 3 years?
The Organization's Professional Indemnity Insurance
Do you purchase Professional Indemnity (E&O) Insurance?
yes
no
If yes please state:
Carrier
Limit of Liability
Deductible
Accounting Department
Do you keep segregated funds or in trust accounts for insurance premiums?
Please provide contact info for your accounting department:
Name
Phone number
Your information
Name:
Position: