Broker Application Form


First Name Last Name Title Phone Ext. Email Password

  1. I am a Registered Insurance Broker or Agent in the Province indicated on the Application and also in any Province in which I provide any Product represented to be Insurance.
  2. I will abide by any and all applicable Federal - Personal Information and Protection Electronic Documents Act (PIPEDA), Provincial and Provincial Insurance Regulator’s Privacy Regulations and Policies with respect to keeping all Personal and Corporate Information gathered in the process of obtaining Insurance strictly confidential. A link to PIPEDA may be found here. I will adhere to any and all applicable Federal, Provincial and Provincial Insurance Regulator’s Policies and Regulations with respect to Licencing, Professional Competence, Ethical Conduct and Insurance- Related Financial Obligations.
  3. As a representative of my Client for the Purpose of obtaining Insurance, I am authorized to act on their behalf, if necessary, to provide any information required for the purposes of obtaining Insurance.
  4. If I am Registering to this Website on behalf of an Insurance Brokerage or Agency I may share access to the Website with other Brokers or Agents provided:
    1. Those person(s) are in compliance with agreements 1 to 4 above
    2. Those person(s) are working on my behalf, under my authority
    3. Those person(s) are working within the physical confines of the Brokerage or Agency indicated on the Registration form.
  5. Any Signature entered electronically during the process of obtaining Insurance from this Website shall be considered a legal, valid and binding signature.
Errors: Please correct all errors indicated in red above