For information on the 2022 Atlantic Insurance Brokers Convention, please visit brokersconvention.ca
Brokerage Firm
Address
City
Prov/State== select == ==Canada== AB BC MB NB NL NS NT NU ON PE QC SK YT ==USA== AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MR MS MT NC ND NE NH NJ NM NN NV NY OH OK OR PA PL PO PR RI SC SD TN TT TX UT VA VI VT WA WI WV WY
Country== select == Canada United States --- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe
Postal/Zip Code
Website
General Brokerage E-mail (for public)
Honorific== select == Mr. Ms. Miss Mrs. M. Mme. Dr. Hon.
First Name
Middle Name/Initial
Last Name
Title/Position
Phone (xxx-xxx-xxxx)
Fax (xxx-xxx-xxxx)
E-mail (for IBANS related emails)
Professional Designations
Are you a licensed broker? Y N
License Number
Level of licensing
Role (check all that apply) Manager personal Lines Manager commercial lines Producer Customer Service Representative Branch Manager Accounting contact PD contact other
Please complete questions (a) or (b) if applicable
a) Are you under 40 years of age and interested in becoming a member of the Young Broker Network:
Y N
Date of Birth(month) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ,
Would you like to assist with YBN events? If yes, please identify or list any special skills/talents or experience below.
b) Are you over 40 years of age, but new to the insurance industry within the last 5 years, and would like to receive Networking Information:
If yes, please enter your date of hire
Number of Years in Business
Agency License Number
What is your organization's anticipated enrollment for CAIB courses this year?
General insurance companies represented in office AVIVA Anderson- McTague & Assoc. Antigonish Farmers Mutual BI&I Coast Underwriters ENCON Ecclesiastical Insurance Echelon Economical Gore Mutual Guarantee Company of North America Insurance Company of PEI Intact Kings Mutual Kingsway General Lloyd’s Lombard Canada L’unique General Insurance Marsh Canada Metro General Nordique Insurance Northbridge Insurance Pafco Pembridge Portage La Prarie Portage Mutual Premier Marine RSA Sovereign General Sunderland Marine Totten Group Travelers UCAI Waterloo Wawanesa Wynward Insurance Zurich Canada Other:
Annual Premium Volume Of Brokerage (Commercial and Personal)== select == Less than 500,000 500,000 to 1 M 1 M to 2 M 2 M to 3 M 3 M to 5 M 5 M to 7 M 7 M to 10 M 10 M to 20 M Over 20 M
What percentage of your business is:
Do you sell Life Insurance? Y N
Do you sell Accident and Health? Y N
Errors and Omissions Carrier
If you participate in IBANS E&O program, please provide the person in your brokerage who is responsible for the E&O Program:
Name of Fidelity Carrier
Name of financial institution where trust account is maintained
Is brokerage owned or controlled (majority interest) by any insurer or financial institution (If yes, firm is ineligible for corporate membership but may be eligible for associate membership - non-voting) Y N
Do agency agreements prohibit the representation of other insurers or groups of insurers (If you can represent only one company you are ineligible for corporate or associate membership) Y N
Has your brokerage completed the Best Practices Program through IBANS Y N
Do you consent to receive email communications from us? Y N
Yes I/We hereby agree to observe strictly the By-laws, Rules and Regulations and Code of Ethics of the Insurance Brokers Association of Nova Scotia (IBANS), as it now is, or may hereafter be constitutionally amended, holding faithfully to the spirit as well as to the letter of said By-laws, Rules and Regulations and Code of Ethics, and also agree that violation by another broker shall not be deemed as in any manner waiving my/our obligations under this agreement.
Yes I hereby confirm that the information contained in this application is correct and authorize the Insurance Brokers Association of Nova Scotia (IBANS) to verify the information given with the appropriate sources.
