Organization
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 Kosovo Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine 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 Serbia 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 Zambia Zimbabwe
Postal/Zip Code
Website
Honorific== select == Mr. Ms. Miss Mrs. Dr.
First Name
Middle Name/Initial
Last Name
Formal first name
Title/Position
Phone (xxx-xxx-xxxx)
E-mail (for IBAS related emails)
Level of licensing== select == Not Licensed Restricted Auto Licence Level 1 Licence Level 2 Licence Level 3 Licence
Year started in the insurance industry
Year brokerage was established
Which of the following insurance companies are represented by your brokerage (check all that apply)? AVIVA Canada GMS Intact Insurance My Mutual Insurance Mutual Fire Insurance Northbridge Insurance Optiom Inc. Palliser Hail Insurance Company Peace Hills General Insurance Portage Mutual Insurance Red River Mutual RSA Canada Saskatchewan Blue Cross Saskatchewan Mutual Insurance SGI CANADA Travelers Canada Wawanesa Mutual Insurance Company Wynward Insurance Group
List any other insurance companies represented by your brokerage (Please separate with commas)?
Do you have employees that deliver services in a language other than English (check all that apply)? American Sign Language Arabic Bengali Bisaya Cantonese Cree Dene French German Hindi Italian Karenic Korean Mandarin Pangasinan Portuguese Punjabi Russian Spanish Tagalog Ukrainian Urdu Not Applicable Other Other Languages Spoken:
Name of sponsoring company== select == AVIVA Canada GMS Intact Insurance My Mutual Insurance Mutual Fire Insurance Northbridge Insurance Optiom Inc. Palliser Hail Insurance Company Peace Hills General Insurance Portage Mutual Insurance Red River Mutual RSA Canada Saskatchewan Blue Cross Saskatchewan Mutual Insurance SGI CANADA Travelers Canada Wawanesa Mutual Insurance Company Wynward Insurance Group Other:
Is brokerage owned or controlled (majority interest) by any insurer or financial institution Y N
Owners and/or shareholders
Proxy holder
Does the Applicant hold a valid Property and Casualty insurance license? 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 of the Insurance Brokers Association of Saskatchewan (IBAS), 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 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 Saskatchewan (IBAS) to verify the information given with the appropriate sources.
Yes I agree to adhere to the BIP Logo Guidelines
Yes I hereby agree and acknowledge that, as a member of the Insurance Brokers Association of Saskatchewan (IBAS), our brokerage will automatically be enrolled in IBAS’s Consumer Protection Bond (CBP) until a time that IBAS is formally notified in writing of our brokerage’s intention to opt out. I acknowledge there is no additional cost to participate in the CBP program, nor shall IBAS remit compensation should our brokerage opt out. By participating in the CBP program, I also hereby agree that our brokerage, its directors, its officers, and its staff shall save harmless and indemnify IBAS from any claim, loss, costs, suits, damages, counsel fees, and expenses, which the surety provider (SGI CANADA) sustains by reason of executing the CBP.
