Online Broker Application

Contact Information

Broker Application

General Information
Present Book Of Business
Insurer Volume Branch Telephone #
Personnel
Name Position Certification Time with Firm
Background Information
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.

Present Insurers and Brokers
Consent
  1. Agrees that all information contained herein is true and correct to the best of their knowledge and belief,
  2. 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.
  3. 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