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GENERAL INFORMATION

Office

Title/Position

Honorific
== select == Mr. Ms. Miss Mrs. M. Mme Dr. Hon.

First Name

Last Name

E-mail (for RCCAQ related emails)

Certificate no.

Do you consent to receive email communications from us?
 Y    N

Date of birth

Sex
 Male    Female

Role (check all that apply)
 Manager  
 Broker  
 Staff  
 Administrator  
 Administrator staff  

Address

City

Prov/State
== select == AB BC MB NB NL NS NT NU ON PE QC SK YT Other

Postal/Zip Code

Country
== select == Canada United States

Phone

Mobile

Fax

General Brokerage E-mail (for public)

Website

AMF no.

Language of communication
 French    English

ADDITIONAL INFORMATION

Have you used the RCCAQ training service?
 Broker 101-102  
 Web training  
 On-site training  
 Pre-recorded Video Training  

Expiry date of your professional liability insurance

Name of the insurer

Expiry date of your directors and officers liability insurance

Name of the insurer

Expiry date of your group health insurance

Name of the insurer

 Yes  - I hereby agree that information provided herein be shared between Courmark, RCCAQ and their partners & vice versa.

COMPANY PROFILE

Name of your banner or group
== select == Assurancia AssurExperts Courtiers-Unis Groupe Jetté Groupe Ultima Intergroupe Intergroupe & AssurExperts

Is your firm a shareholder of a banner?
 Y    N
If yes, which one?

If your firm affiliated with an insurer (shareholder)?
 Y    N
If yes, which one?

WHAT ACTIVITIES ARE YOU LICENSED TO PERFORM ACCORDING TO AMF

 Claims Adjustment  
 Damage insurance  
 Financial planning  
 Group insurance of persons  
 Group savings plan brokerage  
 Insurance of persons  
 Investment contract brokerage  
 scholarship plan brokerage  

VOLUME OF PREMIUM IN $

== select == 0 - 499 999 500 000 - 999 999 1 000 000 - 1 499 999 1 500 000 - 1 999 999 2 000 000 - 2 999 999 3 000 000 - 3 999 999 4 000 000 - 4 999 999 5 000 000 - 7 499 999 7 500 000 - 9 999 999 10 000 000 - 14 999 999 15 000 000 - 19 999 999 20 000 000 - 24 999 999 25 000 000 - 49 999 999 50 000 000 - 99 999 999 100 000 000 and more

Who can view your profile?
 members only    administrators only

I'd prefer receiving the Liaison magazine in its virtual version
 Y    N

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