Please enable JavaScript in your browser to complete this form.123Name *FirstLastLegal StatusIndividual Corporation PartnershipCorporate NameTitle If corporation or partnership, list principals/partners and shareholders AGA Name (If Applicable)MGA Name (If Applicable) Number of Brokers/Advisors12 - 56 - 10 11 - 25 25 - 50 51 - 100 100+Date of BirthAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePhone Number *Email *EmailConfirm EmailWebsite / URLNextProvinces Licensed Newfoundland New Brunswick Nova Scotia Prince Edward Island QuebecOntarioManitobaSaskatchewan AlbertaBritish Columbia Yukon Northwest Territories Nunavut Personal License Number Personal License Expiry Social Insurance Number Corporate License Number Corporate License Expiry Business Identification Number (BIN)Banking InformationHow Would You Like Commission Paid?PayPalDirect Deposit PayPal AddressEmailConfirm EmailName of Financial InstitutionAddress of Financial InstitutionAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryBranch NumberFinancial Institution Number Account NumberVoid Cheque / Pre-Authorized Deposit Form Click or drag a file to this area to upload. Do You Have Errors and Omissions Insurance Coverage?YesNoPlease Enclose Your Errors and Omissions Insurance Coverage Certificate Click or drag a file to this area to upload. PreviousNextAre you a partner, officer or director or in a non-arms length relationship with any other business?NoYesAdditional InformationAre you currently employed in any other capacity not already identified in this questionnaire?NoYesAdditional Information Have you ever been under any legal order to make monetary payments to another person or business entity, including spousal support?NoYesAdditional Information Are your wages or compensation currently garnished or have you ever had your wages or compensation garnished?NoYesAdditional InformationAre you currently indebted to any insurer or General Agent or other financial services company?NoYesAdditional InformationHave you ever been declared bankrupt?NoYesAdditional InformationHave you ever made a voluntary assignment into bankruptcy?NoYesAdditional Information Have you ever made a consumer proposal under any legislation relating to bankruptcy or insolvency?NoYesAdditional InformationAre you currently an undischarged bankrupt?NoYesAdditional InformationAre you currently a conditionally discharged bankrupt?NoYesAdditional InformationHave you ever been a controlling shareholder, or officer of a corporation that was declared bankrupt, or placed in receivership, or made a voluntary assignment in bankruptcy, made a proposal under any legislation relating to bankruptcy or insolvency, or is currently not discharged or conditionally discharged?NoYesAdditional Information Has any partnership or corporation, of which you are or were at the time of such event a partner, officer, director or a controlling shareholder, ever pleaded guilty or been found guilty of an offence under any law of any province, territory, state, or country, or is any such partnership or corporation currently the subject of an investigation or other charges?NoYesAdditional InformationHave you ever pleaded guilty or been found guilty of an offence under any provincial or federal law in Canada or any other country , for which you have not been pardoned?NoYesAdditional InformationHave you or, if incorporated, the corporation ever been refused registration or a licence under any legislation which required registration or licensing to deal with the public in any capacity (eg. insurance agent, RIBO broker, mutual funds salesperson, securities dealer, motor vehicle dealer) in any province, territory, state, or country; or have you held such a license and been the subject of a disciplinary proceeding?NoYesAdditional InformationHave you ever been disciplined by a regulator in any sector of the financial services industry?NoYesAdditional InformationAre you or, if incorporated, the corporation currently being investigated by a regulator in any sector of the financial services industry?NoYesAdditional InformationHave you ever been terminated or resigned, or had any contracts cancelled which you held with any financial services company because you were accused of violating insurance or investment related statutes, regulations, rules, or industry standards of business conduct?NoYesAdditional InformationAre you currently, or is there any reason to believe that in the future you will be, under any legal restriction or impediment which would prevent you from lawfully carrying on the business of insurance agent or broker?NoYesAdditional Information Are you or, if incorporated, the corporation currently involved in any unresolved client complaints?NoYesAdditional InformationHas any policy or application for errors and omissions insurance on your behalf ever been declined, cancelled or renewal refused?NoYesAdditional InformationDo you have written and up-to-date privacy compliance policies and procedures?NoYesDo you have a standard advisor disclosure statement related to managing conflicts of interest that you provide to clients?NoYesAdditional InformationSubmit [sinclair-form-debug]
