Premier Marine Broker Application

Broker Appointment Application Form A

Please have head-office complete Broker Appointment Application FORM A.

Please have each branch complete one Branch Information Supplemental FORM B, if applicable.

Forms can be completed online @ www.premiergroup.ca

Section 1: General Information
Legal name of Brokerage:
Address: / City: / Province: / Postal Code:
Telephone: / Fax: / Website:
Principals / Owners Position Email
Have any employees been reprimanded by Insurance Council in the past 5 years? / Yes / No
Have any employees been convicted for any criminal office in past 10 years? / Yes / No
Have you had any pending or successful complaints relating to Privacy Act? / Yes / No
Is applicant involved in any business other than insurance / Yes / No
If yes to any of the above questions: attach document with details:
Do you have and use a trust account for all trust funds? / Yes / No
Are all staff properly licensed with the provincial councils they conduct business? / Yes / No
Section 2: Errors and Omissions
Insurer: / Policy Number: / Limits: / / Expiry Date:
Have you had any claims in the past 5 years? / Yes / No
If yes: attach document with details:
Section 3: Key Personnel
Position / Name / E-mail Address and Telephone #
Commercial Manager
Personal Manager
Claims Manager
Accounting Manager / Contact
Centralized Point of Contact for Policy Documentation (if applicable)
Section 4: Markets Please complete from largest premium volume to smallest after your sponsor.
Contracted Markets / Years Appointed / Annual Premium (excluding auto) / % Commercial
Sponsor: / $
2. / $
3. / $
4. / $
5. / $
Section 5: Non Contract Carriers, MGA and Wholesalers From largest premium volume to smallest.
Years Appointed / Annual Premium (excluding auto) / % Commercial
1. / $
2. / $
3. / $
4. / $
5. / $
Section 6: Key Commercial Lines Contacts
Name / E-mail Address and Telephone # / Product Interest
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Section 7: Key Personal Lines Contacts
Name / E-mail Address and Telephone #

Authorized Signature

Print Name / Signature / Date

Forms to be returned 30 days after receipt as follows:

By Mail: By Fax:

Premier Canada To: Broker Appointment Processing Team

Broker Appointment Processing Team 604-669-2675

625 Howe St., Suite 300,

Vancouver B.C., V6C 2T6

By Email: Please scan and attach in pdf format.

Privacy Policy

Premier Marine takes care to protect your privacy. We have taken steps to safeguard the confidentiality of information which identifies your personal information against unauthorized access, amendment or deletion and to ensure access is only granted to appropriate persons and only to the extent necessary. This is in accordance with The Personal Information and Protection of Electronic Documents Act (PIPEDA) of which all organizations subject to the Act must comply.

Please visit our website for further information about us and our products.

www.premiergroup.ca

Do not fill in for processing purposes only

Received: / Completed: / Processed: / Signed:

Branch Information Supplemental Form B

Forms can be completed online @ www.premiergroup.ca

Please complete one for each Branch:

Legal name of Brokerage:
Address: / City: / Province: / Postal Code:
Telephone: / Fax:

Key Personnel:

Position / Name / E-mail Address and Telephone #
Commercial Manager
Personal Lines Manager
Claims Manager
Accounting Manager / Contact
Centralized Point of Contact for Policy Documentation (if applicable)

Key Commercial Lines Contacts

Name / E-mail Address and Telephone # / Product Interest
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial
Construction Professional Liability
Environmental Commercial Marine
All Other Commercial

Key Personal Lines Contacts

Name / E-mail Address and Telephone #