CAILBA MEMBERSHIP FORM


AGENCY INFORMATION
Information about the agency.
Agency Name *
Enter the name of your agency.
Agency Address *
Enter the street number, name and direction.
Suite / Unit
Enter suite or unit number or additional address details.
Agency City *
Enter the city where your agency is located.
Province *
Postal Code *
Use format A1A 1A1.
Phone *
User format 111-111-1111
Fax *
User format 111-111-1111
Website Address
Use format www.name.domain
Type of Business


PRINCIPLES INFORMATION
This is the designated "key contact", empowered to vote on behalf of the agency.
Your Name *
Your First & Last name
Title *
Enter your title
Years in Brokerage *
Enter the number of years you have in the brokerage
Your E-Mail Address *

to you at this address
Choose a Login Name (User ID) *
It must be 4 or more characters in length and may
only contain small letters, numbers, and
the underscore '_'
Choose a Password *
Must be 4 or more characters
Confirm your password *
Enter password again
AGENCY OFFICER NAME
Please indicate the agency contacts responsible for each of the following area.
Privacy Contact Name
Enter the contact's full name
Privacy Contact Email
Enter the contact's email address. User format name@website.domain
Technology Contact
Enter the contact's full name
Technology Email
Enter the contact's email address. Use format name@website.domain
Marketing Contact
Enter the contact's full name
Marketing Email
Enter the contact's email address. Use format name@website.domain
Compliance Contact
Enter the contact's full name
Compliance Email
Enter the contact's email address. Use format name@website.domain
COMMITTEE
Indicates which committee most appeals to you. Committee participation is voluntary. Please contact info@cailba.ca for details
Committee Preference


MEMBERSHIP TYPES/FEES
Please review and indicate the membership type most appropriate for your agency

Independent/Corporate MGA (Managing General Agent): $1250.00 + HST/GST
An established independent or corporate licensed life brokerage agency selling Life and Health Insurance through life insurance agents of brokers. Members are subject to pay all dues and assessments.

Industry Supplier: $3125.00 + HST/GST
An established independent or corporate licensed life brokerage agency selling Life and Health Insurance through life insurance agents of brokers. Members are subject to pay all dues and assessments.

Industry Solution Provider $3125.00 + HST/GST
An established independent or corporate licensed life brokerage agency selling Life and Health Insurance through life insurance agents of brokers. Members are subject to pay all dues and assessments.

Membership Type *
Payment System *

DISCLAIMER AND APPROVAL
In submitting this application, I attest the information given herein is complete and correct to the best of my knowledge. Further, I authorize CAILBA officers and/or agents to conduct inquiries and to obtain the standing of this agency and its principles in the provinces and with the companies with which this agency does business. I further agree, if accepted for membership, to comply with the CAILBA Bylaws, Policies and Statement of Responsibilities.
BILLING ADDRESS INFO








Powered by aMember Pro membership software