SECTION A – YOUR COMPANY INFORMATION...6. Please provide a copy of your financial statements, specifying the date that the information was produced. If your companyis a member of

Echelon Insurance Page 1 of 8 Distribution Partner Contract Application (07-2019)

DISTRIBUTION PARTNER CONTRACT APPLICATION

Please select the lines of business that you would like to write.

Personal lines – property Commercial lines – property and casualty Long haul trucking Personal lines – auto Commercial lines – auto Surety

SECTION A – YOUR COMPANY INFORMATION

1. Please provide the ownership and address details for your company.

Company information

License information

Address information

Company name: ___________________________________ Website: ___________________________________ Contact name: ___________________________________ Contact email: ___________________________________ Date of establishment: ___________________________________ Primary telephone number ___________________________________ Primary fax number ___________________________________

License number: ___________________________________ OWNERSHIP INFORMATION

Corporation Partnership Sole Proprietorship Member of a holding company Other:

PRIMARY ADDRESS Street address: ____________________________________ City: _______________________________ Province: Postal code: _____________ MAILING ADDRESS Street address: ____________________________________ City: _______________________________ Province: Postal code: ____________

2. Please list all of your sub-office locations or sub-companies.

Sub-office name Street address City Province Postal code

3. Please list your company’s principals, managers, producers and other key staff.

Name Job title License # Ownership and % of shareholding

Years of experience Years with

company

4. Please list any associations or consolidation groups that your company is a member of.


SECTION B – LICENSE, FINANCIAL AND INSURANCE INFORMATION

5. Select the business lines that your company is licensed to write by province.

AB BC MN NB NL NS NT NU ON PE QC SK YT

Property and casualty insurance: Commercial Lines Personal Lines Travel insurance Surety Mortgage insurance Other

6. Please provide a copy of your financial statements, specifying the date that the information was produced. If your company is a member of a holding company, please submit the holding company’s financial information along with the date that the information was produced.

I will submit copies of my financial statements by way of email to [email protected] This information was produced on _________________________ .

I will submit copies of my financial statements by way of mail.

I will not submit financial statements, but will provide information upon personal request.

7. Does your company have an in-trust account? If so, please provide your account number and the details of your financial institution below.

No, my company does not have a trust account.

Yes, my company has a trust account.

Account number ____________________________________________________________ Name of financial institution ____________________________________________________ Address of financial institution __________________________________________________ __________________________________________________________________________

8. Has the Principal or Owner of your company ever been declared bankrupt, made a voluntary assignment into bankruptcy, made a consumer proposal under any legislation relating to bankruptcy or insolvency, or is the Principal or Owner currently an undischarged bankrupt or conditionally discharged bankrupt? If yes, include trustee's name and address, location of bankruptcy filing, Assignment of Bankruptcy or Receiving Order, Statement of Affairs, Proposal, Discharge, and an explanation as to the circumstances.

Yes No

9. Has the Principal or Owner of your company ever been a controlling shareholder or an officer of a corporation which was declared bankrupt, made a voluntary assignment in bankruptcy, placed in receivership, made a proposal under any legislation relating to bankruptcy or insolvency, or is currently an undischarged or conditionally discharged bankrupt? If yes, include trustee's name and address, location of bankruptcy filing, Assignment of Bankruptcy or Receiving Order, Statement of Affairs, Proposal, Discharge, and an explanation as to the circumstances.

Yes No

mailto:[email protected]


10. Has any partnership or corporation which the Principal or Owner of your company was at the time of such event a partner, officer, director or a controlling shareholder, ever plead guilty or been found guilty of an offense under any law of any province, territory, state, or country, or is any such partnership or corporation currently the subject of such charges?

Yes No

11. Has the Principal or Owner of your company or a Licensed Employee ever plead guilty or been found guilty of an offense under any law of any federal statute or law of any province, territory, state or country, for which they have not been pardoned or are they currently the subject of any such charges? Some examples of these offenses are fraud, theft, weapons charges, drug trafficking, physical assault, impaired driving, tax evasion and human rights violations. The disclosure of minor traffic infractions such as speeding or parking violations is not required.

Yes No

12. Has the Principal or Owner of your company or a Licensed Employee ever been refused registration, or a license under any legislation which required registration, or a license to deal with the public in any capacity (e.g. insurance representative, mutual funds representative, securities dealer, motor vehicle dealer) in any province, territory, state or country, or have they held such a license and been the subject of disciplinary proceedings? If yes, provide details including penalties imposed.

Yes No

13. Has the Principal or Owner of your company or a Licensed Employee ever been reported to a financial services regulator resulting in disciplinary measures? If yes, provide details including penalties imposed.

Yes No

14. Has the Principal or Owner of your company or a Licensed Employee ever been terminated or resigned, or had any contracts cancelled which they had held with any financial services company because they were accused of violating insurance or investment related statutes, regulations, rules or industry standards of business conduct?

Yes No


15. Are there any pending client complaints or any events which may result in a claim against the Principal or Owner of your company or a Licensed Employee, either from a provincial regulator, another Insurer, or a client directly?

Yes No

16. Please list any professional insurance policies that your company has purchased.

Policy type:

Policy type:

Policy type: Carrier name ___________________________________

Carrier name ____________________________________

Carrier name ___________________________________

Policy limit $_________________ Policy limit $_________________ Policy limit $_________________

Deductible $_________________ Deductible $_________________ Deductible $_________________

17. Please provide any sponsorship information below, if applicable.

Current sponsoring insurance company name Have you changed sponsors in the last 5 years? If yes, please explain below.

Yes No

Have you ever been declined sponsorship? If yes, indicate the reason(s) for decline below.

Yes No

Are you applying to change your sponsor? If yes, please indicate the reasons for the change of sponsorship below.


SECTION C – VOLUME AND MARKETS

18. Please indicate your business volume for the regional markets that your company does business in:

Region: ___________________________ Population: _________________________



Residential $ ______________ Residential $ ______________ Residential $ ______________

Commercial $ ______________ Commercial $ ______________ Commercial $ ______________

Industrial $ ______________ Industrial $ ______________ Industrial $ ______________

19. Please describe your company’s annual volume and mix of business by line.

Personal lines Commercial lines Commercial lines Volume ($ or %)

Volume ($ or %)

Volume ($ or %)

Personal property $ _______ / ____% Commercial property $ _______ / ____% Surety $ _______ / ____%

Personal auto $ _______ / ____% Commercial auto $ _______ / ____% Long haul trucking $ _______ / ____%

Non-standard auto $ _______ / ____% Commercial liability $ _______ / ____% Other $ _______ / ____% Recreational vehicles $ _______ / ____% Personal lines total $ _______ / ____% Commercial lines total $ _______ / ____% Other lines total $ _______ / ____%

20. Please outline the approximate volume that you would plan to write with Echelon Insurance over the next 24 months.

Personal lines ($) Commercial lines ($) Other lines ($) Year 1 Year 2

Year 1 Year 2

Year 1 Year 2

Personal property ________ _______ Commercial property ________ _______ Surety ________ _______

Personal auto ________ _______ Commercial auto ________ _______ Long haul trucking ________ _______

Non-standard auto ________ _______ Commercial liability ________ _______ Other ________ _______

Recreational vehicles ________ _______ Personal lines total ________ _______ Commercial lines total ________ _______ Other lines total ________ _______


21. Indicate the primary markets that you represent from largest to smallest in the space provided below.

Market #1: _______________________________________________ Years represented: ______

Market #2: ______________________________________________ Years represented: ______

Business lines Volume Loss ratio

Business lines Volume Loss ratio Commercial lines Commercial lines

Commercial property $ _________________ ______ % Commercial property $ _________________ ______ % Commercial auto $ _________________ ______ % Commercial auto $ _________________ ______ % Commercial liability $ _________________ ______ % Commercial liability $ _________________ ______ %

Personal lines Personal lines

Personal property $ _________________ ______ % Personal property $ _________________ ______ % Personal auto $ _________________ ______ % Personal auto $ _________________ ______ % Non-standard auto $ _________________ ______ % Non-standard auto $ _________________ ______ % Recreational vehicles $ _________________ ______ % Recreational vehicles $ _________________ ______ %

Other lines Other lines

Surety $ _________________ ______ % Surety $ _________________ ______ % Long haul trucking $ _________________ ______ % Long haul trucking $ _________________ ______ %

Do you have underwriting/issuing authority with this market? Yes No

If so, how do you interface with them (Broker management system, Insurer system)?






Business lines Volume Loss ratio Commercial lines Commercial lines Commercial property $ _________________ ______ % Commercial property $ _________________ ______ % Commercial auto $ _________________ ______ % Commercial auto $ _________________ ______ % Commercial liability $ _________________ ______ % Commercial liability $ _________________ ______ %

Personal lines Personal lines

Personal property $ _________________ ______ % Personal property $ _________________ ______ % Personal auto $ _________________ ______ % Personal auto $ _________________ ______ % Non-standard auto $ _________________ ______ % Non-standard auto $ _________________ ______ % Recreational vehicles $ _________________ ______ % Recreational vehicles $ _________________ ______ %

Other lines Other lines Surety $ _________________ ______ % Surety $ _________________ ______ % Long haul trucking $ _________________ ______ % Long haul trucking $ _________________ ______ %









Business lines Volume Loss ratio Commercial lines Commercial lines Commercial property $ _________________ ______ % Commercial property $ _________________ ______ % Commercial auto $ _________________ ______ % Commercial auto $ _________________ ______ % Commercial liability $ _________________ ______ % Commercial liability $ _________________ ______ % Personal lines Personal lines Personal property $ _________________ ______ % Personal property $ _________________ ______ % Personal auto $ _________________ ______ % Personal auto $ _________________ ______ % Non-standard auto $ _________________ ______ % Non-standard auto $ _________________ ______ % Recreational vehicles $ _________________ ______ % Recreational vehicles $ _________________ ______ % Other lines Other lines Surety $ _________________ ______ % Surety $ _________________ ______ % Long haul trucking $ _________________ ______ % Long haul trucking $ _________________ ______ %





22. Please list any markets that you actively compete with in your region, and do not represent.

23. Please list any brokers that you compete with in your region.

24. Does your company have an online presence? If so, how much of your annual volume is generated online?


SECTION E – OPERATIONS

25. Do you have a formal business plan for your company? If yes, please describe your plan at a high-level in the space provided below.

26. Do you have a formal succession/perpetuation plan? If so, please describe your plan at a high-level in the space below.

27. What is the structure for compensation in your office for staff including Producers and Customer Service Representatives?

28. Which Office Automation/Broker Management System (BMS) are you using?

29. Would you like to be set up for Upload, Download and/or eDocs with Echelon? If so, please list which ones below.

Upload/Download eDocs

30. Do you use any rating tools (AutoRater, Power Broker, etc.)? If so, please specify below.

31. Additional comments.

Completed by:

Name Date Signature

Documents

SECTION A – YOUR COMPANY INFORMATION...6. Please provide a copy of your financial statements, specifying the date that the information was produced. If your companyis a member of