Legal name of organization
Principal place of business and address
Postal address (if different)
Web site address
Type of organization
Publicly held company
Privately held corporation
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?
Please provide details
Nature of Business
Please check the box which best reflects the Applicant's main business activity
Retail Insurance Broker
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?
If yes please state:
Limit of Liability
Do you keep segregated funds or in trust accounts for insurance premiums?
Please provide contact info for your accounting department: