New Associate Sign-up

Contact Information

Brokerage Firm

Address

City

Prov/State

Country

Postal/Zip Code

Website

General Brokerage E-mail (for public)

Owner/Principal Information

Honorific

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

Young Broker or New to Industry

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
,

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:

Y N

If yes, please enter your date of hire

General Information

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)

What percentage of your business is:

Auto

Home

Commercial

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
Phone
Email

Errors and Omissions Policy #

Errors and Omissions Policy Expiry

Name of Fidelity Carrier

Fidelity Policy #

Fidelity Policy Expiry

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

Privacy Information

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.