Premier Broker Application Form

Contact Details

Please fill in your contact details and address information. A VALID email address and contact number are required to allow Premier to follow up with your broker application.

E-mail Address: *

Registered Name: *

Broker License Number: *

Contact Number: *

Fax Number: *

Website:

Address: *

City: *

Postal Code: *

Principals: *

Who are the principals of your brokerage? Provide as much information as possible to help with the application process.

History of Brokerage: *

Please supply a brief history of your current brokerage.

Key Personnel
Provide the name, years of experience and contact email for the 3 key personal departments listed below.

Personal Department:

Years of experience:

Email Address:

Commercial Department:

Years of experience:

Email Address:

Accounting Department:

Years of experience:

Email Address:

Contracted Markets

1. Insurer:

1. Years Appointed:

2. Insurer:

2. Years Appointed:

3. Insurer:

3. Years Appointed:

4. Insurer:

4. Years Appointed:

5. Insurer:

5. Years Appointed:

Errors and Omission

Insurer:

Policy Number:

Limit:

5 Year Claim History:

Number of licensed employees for PERSONAL LINES:

Number of licensed employees for COMMERCIAL LINES:

Have any employee been reprimanded by Insurance Council in the past 5 years? If so explain below.:

Do you have and use a trust account?:

Yes

Attach Errors and Omission Certificate:

Online Quoting & Binding

Learn more about our online quoting & binding system

Products

Environmental Lines

Professional Liability (E&O, and D&O)

Commercial Lines

Personal Lines

Marine - Pleasurecraft

Marine - Commercial

Prize Indemnity

Marine Pleasurecraft USA

Locations

Head Office: Vancouver BC 604-669-5211

Toronto ON 416-365-0444

London ON 519-850-1610

Seattle WA, USA 800-589-4208

Premier Broker Application Form

Online Quoting & Binding

Products

Locations

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