Broker Registration – Forward Insurance

Registration Type

Register As(Required)

JET User Account (existing Brokers)

New Brokerage Application

Brokerage / Branch Details

Brokerage(Required)

Branch Address(Required)

Street Address City Province Postal Code

User Details

Name(Required)

Email Address(Required)

Brokerage Details

Legal Name of Brokerage(Required)

Trading Name(Required)

Head Office Details

Head Office Phone Number(Required)

Head Office Address(Required)

Street Address Address Line 2 City Province Postal Code

Branch Details

List of Branches

Name (If Different)

Address

City

Province

Phone

To add multiple click the plus icon on the right side of this field

List of Branches Upload Spreadsheet (Optional)

Accepted file types: xlsx, xls, Max. file size: 32 MB.

Contracts, MGA's & Wholesalers

Contracts - List all contracts with insurance companies(Required)

Company Name

Date Appointed (mm/dd/yyyy)

To add multiple click the plus icon on the right side of this field

List all MGA’s & Wholesalers you do business with(Required)

Company Name

Annual Premium $

To add multiple click the plus icon on the right side of this field

Points of Contact

Commercial Lines(Required)

Name

Title

Email Address

Phone

To add multiple click the plus icon on the right side of this field

Personal Lines(Required)

Name

Title

Email Address

Phone

To add multiple click the plus icon on the right side of this field

Overall Contract Relationship(Required)

Name

Title

Email Address

Phone

To add multiple click the plus icon on the right side of this field

Electronic Data Transmission Contacts

Accounting(Required)

Email Address

To add multiple click the plus icon on the right side of this field

Bulletins(Required)

Email Address

To add multiple click the plus icon on the right side of this field

Product Training(Required)

Email Address

To add multiple click the plus icon on the right side of this field

Canada’s Anti-Spam Law (CASL) requires consent for our electronic messages.(Required)

I consent to Forward sending emails to my Brokerage.

Platform User Logins

JET is our self-serve platform where you can quote & issue your documents in real time.

For all brokerage accounts, we require you to provide a *General email address. This email address will be sent a copy of all policy activity (for all users). This serves as an excellent audit trail for brokerage management. (Consider – forward@abcbrokerage.com).

Each individual user’s login will be their company email. Every user can view all brokerage transactions. The platform records activity by individual user.

When a user enters a policy transaction, the individual user will receive the document in their company email and the brokerage will also receive an email in the *General email address provided below for the Brokerage.

General Email Address(Required)

Required for general policy deliverance

User Accounts

Name

Email Address

Branch City

To add multiple click the plus icon on the right side of this field

User Accounts Upload Spreadsheet (Optional)

Accepted file types: xlsx, xls, Max. file size: 32 MB.

Errors & Omission Coverage

Insurer(Required)

Policy #(Required)

Limit(Required)

Expiry Date (mm/dd/yyyy)(Required)

Has there been any E&O claims in the past 5 years?(Required)

Yes

No

E&O Claims Details(Required)

Licencing - List Current Licences(Required)

Province

Licence #

Expiry Date (mm/dd/yyyy)

To add multiple click the plus icon on the right side of this field

Has the Brokerage had any license(s) suspended, terminated or been fined?(Required)

Yes

No

Suspended Licence Details - List each issues and explain(Required)

Has the Brokerage or any licensed individual representing the Brokerage been reprimanded by a Regulator in the past 5 years?(Required)

Yes

No

Reprimand Details - List each issues and explain(Required)

Acknowledgement

Consent(Required)

I declare that I am authorized to disclose the information in this application and authorized to request a new Broker Code on behalf of the legal entity listed in this application.

Name(Required)

First Last

Title(Required)

Date (mm/dd/yyyy)(Required)

You are on Your Way to Insurance. Faster.

Registration Type

Brokerage / Branch Details

User Details

Brokerage Details

Head Office Details

Branch Details

Contracts, MGA's & Wholesalers

Points of Contact

Electronic Data Transmission Contacts

Platform User Logins

Errors & Omission Coverage

Acknowledgement

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