Insurance Broker Information for Company Appointment by ijk77032

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									                                                                                                             Executive Peace of Mind, Worldwide.



Insurance Broker Information for Company Appointment
Applicant Information                                                             (Applicant’s name as it appears on the Provincial license – Attach copy of license)

First name:                                                                        Last name:
Agency name:
Address:                                                                          City:
Province:                               Postal code:                              Country:
Province requested:                                                                    Resident           Non-resident
Name of entity receiving commission (Entity receiving commission must              ►
be licensed – attach copy of license)

Is entity licensed in requested Province?              Yes             No
Broker Information
Broker name:
Address:                                                                          City:
Province:                               Postal code:                              Country:
Broker telephone number:                                                          Broker fax number:
Provincial license*:                                                              Corporate Acts number:
* Attach a copy of your license for each Province in which you intend to submit business.



XN Risk Use
Submitted by:                                                                      Processed by:
Effective date of appointment: (yyyy-mm-dd)
Comments:




                                                                                 XN Risk®
                                                          10 King Street East, Suite 1000, Toronto, ON M5C 1C3
                                           Tel: (416) 340-6420 - Fax: 1-877-908-1837 - Email: uw@xnrisk.ca - www.xn.com

								
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