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Company name

Full name

Preferred language of correspondence

English

French

Full address

Phone number

Email

How did you hear about us?

I am

Insurance agent or broker

Financial planner

Travel agent

I have been in the insurance business for (in years)

and I sell (in premium) travel insurance annually

I am interested in working with MSH

For all my travel insurance needs

For special risks, international students, international traveler, groups, etc.

List, in order of total volume, the travel insurance companies with which you have been contracted during the last 24 months. Indicate the product types for each company.

My client base is located in (check all that apply)

Canada

The United-States

Europe

Latin America

Asia

Middle East

Africa

Other specific areas

Demographic groups I focus on are (check all that apply)

Snowbirds

Families

Groups

Visitors to Canada/Expatriates/Super Visa

Youth/backpackers/International students/International travellers

Other

Are you currently indebted to any insurer or MGA?

Yes

No

Have you ever been declared bankrupt or made voluntary assignment into bankruptcy, or made a consumer proposal under any legislation relating to bankruptcy or insolvency, or are you currently undischarged bankrupt or conditionally discharged bankrupt?

Yes

No

Have you ever been a controlling shareholder, or officer of a corporation that was declared bankrupt, or placed in receivership, or made a voluntary assignment in bankruptcy, made a proposal under any legislation relating to bankruptcy or insolvency, or i

Yes

No

Has a partnership or corporation, of which you are or were at the time of such event a partner, officer, director or a controlling shareholder, ever pleaded guilty or been found guilty of an offence under any law of any province, territory, state or cou

Yes

No

Have you ever been refused registration or a licence under any legislation which required registration or licensing to deal with the public in any capacity (eg. insurance agent, RIBO broker, mutual funds salesperson, securities dealer, motor vehicle deale

Yes

No

Have you ever had any activities reported to, or been disciplined by a financial services or insurance regulator?

Yes

No

Have you ever been terminated or resigned, or had any contract cancelled which you help with any financial services company because you were accused of violating insurance or investment related statutes, regulations, rules, or industry standards of busine

Yes

No

Are you currently, or is there any reason to believe that in the future you will be, under any legal restriction or impediment which would prevent you from lawfully carrying on the business of insurance agent or broker?

Yes

No

Are you licensed?

Yes

No

Additional information