Apply for a Broker Account - Complete the Following Form
To apply for a Broker Account please complete the application form below. Once you are finished press "Continue to Confirmation Page".
>> To apply by fax or mail, click here to download the required forms
* = required field
Brokerage Information
Broker Company Name
*
:
Address Line 1
*
:
Address Line 2:
City
*
:
Province
*
:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Saskatchewan
Yukon
Postal Code
*
:
Phone Number
*
:
Fax Number
*
:
E-mail address
*
:
Website URL:
http://
Principals & CSR Information
Broker Principal(s)
*
:
Title:
Primary IFS Contact
Title:
Primary IFS Contact
Title:
Primary IFS Contact
List of your CSR(s):
E-mail:
Primary IFS Contact
E-mail:
Primary IFS Contact
E-mail:
Primary IFS Contact
E-mail:
Primary IFS Contact
Additional Brokerage Information
Years in business
*
:
Number of offices
*
:
Number of employees
*
:
Number of Producers
*
:
Average Account Size
*
:
$
Annual Volume
*
:
$
Scope of business:
Commercial / Personal Lines
*
:
Commercial
% / Personal
%
Affiliated with a network?
*
:
No
Yes
If Yes, Name of network / group:
Specialty Lines / Programs:
Insurer Information
Primary Insurers
*
:
Contact Name
*
:
Contact Name:
Contact Name:
Contact Name:
Banking Information
Bank Name and Address
*
:
Your Account Manager
*
:
Bank Phone Number
*
:
Bank Fax Number:
Premium Finance Vendor Information
Current Premium Finance Vendors:
Annual Volume Financed:
$
How did you hear about IFS
*
:
Electronic Payment Distribution System (PDS) - optional
Do you want to apply for PDS at this time?
*
:
No
Yes
If Yes, complete the following fields in this section.
Payment Notification Method:
Fax
E-mail
Both
Different Fax for PDS:
No
Yes
If Yes, fax number:
Different E-mail for PDS:
No
Yes
If Yes, e-mail address:
Notification sent Attention:
Institution Number:
Branch Number:
Account Number:
How to enter you banking information
:
1 - This is the cheque number (do not enter this number)
2 - This is the branch number (5 digit number)
3 - This is the institution number (3 digit number)
4 - This is the account number
IN ORDER TO CONFIRM BANKING INFORMATION PLEASE FAX US A VOID CHEQUE AT: 1-800-453-5736
Please enter the content of this image in order to confirm you are a real person
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