Online Broker Application

Contact Information

First Name

Last Name

Company

Phone

Phone Alt

Broker Application

General Information

Applicant

Principals

Address

Phone

Fax

Are you a Designated Individual

Home Address

How did you hear about us?

Present Book Of Business

Insurer	Volume	Branch	Telephone #

Personnel

Name	Position	Certification	Time with Firm

Background Information

Have you ceased doing business with any contracted insurers in the past five years? Please provide full details.

Do you write Life Insurance?

Do you own your P&C Business?

Do you have a Non-Compete Agreement presently?

Are you automated? Which system?

Have you ever been the subject of any disciplinary action by RIBO or any other regulatory body? If so please provide details?

Have you ever declared bankruptcy? Please provide complete details.

Have you or any of your employees ever been the subject of any Errors and Omissions or Bond claim? Please provide complete details.

Business Spread

Class of Business	Premium of Volume	Policy Count
Sub-Standard Auto
Personal Lines
Commercial Lines

Curriculum Vita

Please provide us a resume of the designate including detail as to how the brokerage was started, growth plans and where you see the future of this business.

Resume Upload

Present Insurers and Brokers

Please list all insurers and brokers, not previously mentioned, with which you have business placed.

Consent

Agrees that all information contained herein is true and correct to the best of their knowledge and belief,
Agrees that a consumer report may be requested or a personal or corporate investigation conducted in connection with this application and hereby authorize SurNet Insurance Group Inc. or its agent to obtain such consumer report or to conduct such investigation.
Hereby authorize RIBO, any licensed insurer, the Ontario Insurance Commission or like authority to give SurNet Insurance Group Inc. or its agent any information as they may request to aid in the completion of such investigation. A photographic copy of this authorization shall be as valid as the original.

Date: Sun, Sep 5th 2010, 17:26

I agree to the terms and agreements

Broker Signature

Witness Signature