BROKER INFORMATION FOR CLIENTS CONCERNING
Insert your legal name here
***Instructions: replace all red text <insert your legal name here with your name. Choose applicable insurance companies that you are contracted to represent and delete the other ones. Delete these instructions after.
I, insert your legal name here (the broker), have reviewed the following points with you (the client):
l / I am licensed to be a life insurance agent and have access to the following insurance companies’ products (life insurance and/or group insurance):
§ iA Financial Group / § The Canada Life Assurance Company
§ Equitable Life of Canada / § Allianz Global Assistance
§ iA Excellence / § Assumption Life
§ Others: ______
*These products are administered by Crius Financial Services Corporation (“the Company”), a managing general agency / associate general agency of the listed insurance companies
l / No insurance company holds an ownership interest in my business, nor do I hold an interest in any insurance company.
l / I will be compensated by the insurance company that offer the product you choose and/or by the Company. I am compensated by a sales commission for most products at the time of sale, and may receive a renewal (or service) commission. For certain products, I may receive a referral fee. I may also be eligible for additional compensation, such as bonuses and non-monetary benefits such as travel incentives. This compensation depends on various factors such as the volume or retention of business that I place with a particular insurance company during a given time period.
l / I may provide a referral fee to a third party upon receiving a referral.
l / I will maintain a client file for you. This file contains application forms and documents with personal information related to you, in order for the insurance company to underwrite or issue the products and provide services to you and for me to assess your financial situation, offer appropriate products and services, and to provide ongoing service to you.
This file will be kept in the Company and/or in my office. Access to your file is limited to me, my manager, or persons I have authorized to act on my behalf, when the information is required for the performance of the person’s duties, to the companies I represent in providing, or seeking to provide, products or services to you, to persons you have granted access, and to persons allowed by law.
l / I take the potential of a conflict of interest seriously. I will notify you if there is a conflict of interest of which I become aware in regards to my services. My services will take into consideration your financial needs.
Additional Acknowledgements:
CLIENT ACKNOWLEDGEMENTS
By signing this document,
l / I understand the disclosure made by the broker on the points listed above.
l / I give consent to the broker for the collection, use, and disclosure of my personal information as listed above.
l / I agree to continue discussions with the broker and will inform the broker if any personal information (e.g. contact information) has changed.
l / I understand that I may ask the broker for further information regarding this disclosure.
______/ ______/ Date: / ______
Client’s Name (Print) / Client’s Signature / (mm/dd/yyyy)
______/ ______/ Date: / ______
Broker’s Name (Print) / Broker’s Signature / (mm/dd/yyyy)
**This statement has been prepared by insert your legal name here and insert your legal name here is responsible for its accuracy.
09/16