Oceanic Underwriters Application Form

Contact Details

Please fill in your contact details and address information. A VALID email address and contact number are required to allow Oceanic 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:

Products

Amateur Sports

Adventure Tourism and Recreation

Marine - Commercial

Marine - Pleasurecraft

Locations

Head Office: Western Canada 604-689-1501

Ontario & Atlantic Canada 416-868-9090

Oceanic Underwriters Application Form

Products

Locations

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