Forms and Plugins - Interaction Testing - Red Helm Canada

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Name

First

Last

Legal Status

AGA Name (If Applicable)

MGA Name (If Applicable)

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone Number

Confirm Email

Website / URL

Are you a partner, officer or director or in a non-arms length relationship with any other business?

Are you currently employed in any other capacity not already identified in this questionnaire?

Have you ever been under any legal order to make monetary payments to another person or business entity, including spousal support?

Are your wages or compensation currently garnished or have you ever had your wages or compensation garnished?

Are you currently indebted to any insurer or General Agent or other financial services company?

Have you ever been declared bankrupt?

Have you ever made a voluntary assignment into bankruptcy?

Have you ever made a consumer proposal under any legislation relating to bankruptcy or insolvency?

Are you currently an undischarged bankrupt?

Are you currently a conditionally discharged bankrupt?

Have 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?

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?

Have 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?

Have 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?

Have you ever been disciplined by a regulator in any sector of the financial services industry?

Are you or, if incorporated, the corporation currently being investigated by a regulator in any sector of the financial services industry?

Have 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?

Are 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?

Are you or, if incorporated, the corporation currently involved in any unresolved client complaints?

Has any policy or application for errors and omissions insurance on your behalf ever been declined, cancelled or renewal refused?

Do you have written and up-to-date privacy compliance policies and procedures?

Do you have a standard advisor disclosure statement related to managing conflicts of interest that you provide to clients?

Additional Information

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Forms and Plugins - Interaction Testing - Red Helm Canada | Health, Life and Travel Insurance

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