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AGENCY INFORMATION |
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Agency Name:
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Address:
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Suite / Unit:
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City:
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Province:
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Postal Code:
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Phone:
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Fax:
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Website Address:
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TYPE OF BUSINESS |
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Corporation:
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Partnership:
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Sole Proprietor:
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Other:
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Please Specify
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PRINCIPAL INFORMATION
This is the designated "Key Contact" and empowered to vote on behalf of the Agency |
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First Name:
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Last Name:
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Title:
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# Years in Brokerage:
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Email:
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AGENCY OFFICER NAMES |
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Privacy Contact:
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Privacy Email:
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Technology Contact:
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Technology Email:
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Marketing Contact:
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Marketing Email:
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Compliance Contact:
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Compliance Email:
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DEBT MONITORING SYSTEM (DMS)
Each agency may have up to three(3) Debt Monitoring contacts. In order to gain access to the CAILBA Debt Monitoring System (DMS), each individual will have to sign an agreement. |
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User1 Contact:
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User1 Email:
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User2 Contact:
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User2 Email:
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User3 Contact:
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User3 Email:
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Is the Agency owned, financed, or controlled by an insurance company, insurance employee, and / or an employee of a non-independent agency?
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Is the Agency and all of its officials / officers in good standing in all the Provinces and with which the Agency does business?
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If No, please provide details:
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COMMITTEE
Please indicate which committee most appeals to you. Committee participation is strictly voluntary, if you are interested in participating in a committee, please contact info@cailba.com |
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Company & Industry Relations and Compliance:
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Errors & Omission:
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Membership:
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Technology:
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MEMBERSHIP DUES / FEES
Your application will be pending for approval upon submission. Applicants are approved at the end of each month by the Board of Directors. Once approved, you will become a full member. Membership dues are calculated on a pro-rated basis. For example, if you submit your application in January and approved at the end of the month, your membership will be effective starting the month of February, therefore will pay 11/12 of the annual membership due. Any applications submitted in the last quarter (October - December) of the year will receive the remainder of the year for free and your annual dues collected will be for the following year.
The following are represented as an annual membership. Please check one of the following: |
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Membership Type:
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Independent MGA
(Managing General Agent) - $1,250.00 + $62.50 GST = $1,312.50
An established independent licensed
life brokerage agency selling Life and Health Insurance through
life insurance agents of brokers. Members are subject to pay
all dues and assessments.
Corporate MGA (Managing General Agent)
- $1,250.00 + $62.50 GST = $1,312.50
An established licensed life brokerage agency
selling Life and Health insurance through life insurance agents
or brokers. Members are subject to pay all dues and assessments.
Industry Supplier - $3,125.00 + $156.25 GST = $3,281.25
A life insurance company or supplier to the
industry. Members are subject to pay all dues and assessments. |
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Membership Amount:
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GST:
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Total Due:
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DISCLAIMER AND APPROVAL
In submitting this application, I attest the information given herein is complete and correct to the best of my knowledge. Further, I authorize CAILBA officers and / or agents to conduct inquiries and to obtain standing of this agency and its principals in the provinces and with the companies with which this agency does business. I further agree, if accepted for membership, to comply with the CAILBA Bylaws, Policies and the Statement of Responsibilities. |
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Agency:
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Amount:
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Date:
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