Dealer Information Questionnaire
for
Empire Class Segregated Funds
The following Dealer information is required to initiate the Empire Life FundSERV set-up process:
Registration(Please provide copy of license) / X Investment Dealer/Broker
Dealer Number(s) / 1234
Dealer Legal Name / MGA
Street Address / 211 Main Street, Suite 2
City, Province, Postal Code / Port Stanley, ON N5L 1C4
Phone & Fax Number / Phone 519-782-7730 Fax 519-782-9949
Email Address /
Website Address /
Principal Contact / Title / Colin Baldwin
Phone Number (if different)
Administration Contact Name / Barry Alexander
Administration Phone, Fax, Email / 519-782-7730/519-782-9949
Account Registration / Nominee Intermediary X Client
Type of Back Office System Used / VIRTGATE (COVIRT)
- Sales Representative List
A complete company listing of all sales representatives with their IA codes, address, phone / fax, email address and a branch listing is required. An updated list must be provided whenever any of this information changes. Will be provided when business is done
- Services required by Broker/Dealer
a)Are you an N$M (Net Settlement Messaging) member (If yes, complete the schedule entitled “Net Settlement Arrangements” / N$M / X Commission Only N$M
b)Do you require Net, Mass or Individual settlement on wire orders? / X Individual
Mass
Net
c)Do you require Fax transmission privileges? / X Yes / No
d)Do you require Electronic Switch transmission privileges? / X Yes / No
e)Do you require settlement of wire order redemption for accounts registered in your name without providing backup documentation? / Yes / X No
f)Do you process Client Name to Nominee Name Internal or External Transfers
(If yes, complete “Internal and External Transfers form” / Yes / X No
g)Do you use multiple dealer codes to place Segregated Fund business? / Yes / X No
h)Do you require account inquiry access? / X Yes / No
i)Type of Back office system currently being used? / VIRTGATE (COVIRT)
- Data File Services:
a)Account Reconciliation (AA File) / X Yes / No
b)Month End Reconciliation (AM File) / Yes / X No
c)Sales Commission (AW File) / X Yes / No
d)Service Fees (AS File) / Yes
If yes, frequency
X Monthly
Quarterly / No
e)Settlement Instruction (AF File) / X Yes / No
f)Transaction Reconciliation (AT File) / X Yes / No
- Transaction Reports:
Semi and Annual Statements
/ Dealer Copy / Rep Copy / Client Copya)Client Registered Accounts / Yes X No / X Yes No / Mandatory
b)Nominee Registered Accounts* / Yes X No / Yes X No / Yes X No
c)Intermediary Registered Accounts* / Yes No / X Yes No / As instructed by Intermediary
Transaction Confirmations** / Dealer Copy / Rep Copy / Client Copy
a)Client Registered Accounts / X Yes No / X Yes No / Mandatory
b)Nominee Registered Accounts / Yes X No / Yes X No / Yes X No
c)Intermediary Registered Accounts / X Yes No / X Yes No / As instructed by Intermediary
Please indicate which documents you would like to receive.
*For Nominee and Intermediary Registered Accounts we are required to produce and send a semi-annual and annual statement. Where “no” is elected on the client copy, the dealer will receive the statement. If “yes” is elected for client copy, you can elect “no” to the dealer copy.
If “no” is elected for client copy of the statement, it is the Dealer’s responsibility to ensure that annual statements are delivered to the client reflecting the clients holdings with Empire Life and the statements must adhere to the IVIC guidelines regarding statement production.
**Please note that a Contract Confirmation, which forms part of the contract, will always be sent regardless of the account registration type.
Dated this ______day of ______, 20__.
______
Signature and Title
TM Empire Life and Empire Life Financial Group are trademarks of The Empire Life Insurance Company.
Policies are issued by The Empire Life Insurance Company.
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