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Brokerage Information

Organization

Address

City

Province/State

Country

Postal/Zip Code

Website

General Brokerage E-mail (for public)

Please advise who we should contact in your brokerage regarding any accounting inquiries:

Name
Phone
Email

Owner/Principal Information

Honorific

First Name

Last Name

Title/Position

Phone (xxx-xxx-xxxx)

Fax (xxx-xxx-xxxx)

E-mail (for IBAN related emails)

Please include any other insurance designations you possess

Briefly Explain why you would like to Join the Insurance Brokers Association of NL

Role (check all that apply)
Manager personal Lines
Manager commercial lines
Producer
Customer Service Representative
Branch Manager
Accounting contact
PD contact
other

Please indicate if you are under 40 years of age and would like to become part of our Young Broker Network. If so, please enter your birthday
Y N

Date of Birth
,

General Information

Revenue Level

Region

Year Office Established

Are you a member of another Provinces Brokers Associations, if so please Advise which ones

Does the Insurance Courier Deliver to you?
Y N

Companies you represent

Does your office sell life insurance?
Y N

Name: (Principal, Officer, Partner)

Do you have an E and O policy?
Y N

Briefly Explain why you would like to Join the Insurance Brokers Association of NL

Do you consent to receive email communications from us?
Y N

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