Position Reports - Registered Insurance Brokers of Ontario (RIBO) - Ontario's regulator of general insurance brokers"

I do hereby certify that I am the principal broker as specified in the By-Laws and Regulations under The Registered Insurance Brokers Act, 1990 and to the best of my knowledge and belief this report is complete and correct in all respects.(Required)

Agreed

Firm Name New(Required)

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Firm License Number

Name(Required)

First Last

Email(Required)

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Firm Name(Required)

Firm Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

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Firm Registration Number (Please do not add letters before the number)(Required)

Reporting Date(Required)

Reporting Due Date(Required)

Signoff

Date(Required)

Principal Broker Registration Number(Required)

eSignature(Required)

A. TRUST POSITION

ASSETS

Cash on hand and bank balances of trust accounts

(1) Cash on hand and bank balances of trust accounts

Allowable premiums receivable (include RST if tax liability included in line 10)

(2) Allowable premiums receivable

Less premiums over 90 days

(3) Less premiums over 90 days

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

Allowable premiums receivable

(4) Allowable premiums receivable

Investments held in trust as allowed by Regulation

(5) Investments held in trust as allowed by Regulation

Total Assets

(6) Total Assets

LIABILITIES

Insurance premiums payable

(7) Insurance premiums payable

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

Prepaid premiums

(8) Prepaid premiums

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

Refunds due to insureds

(9) Refunds due to insureds

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

Retail Sales Tax Payable (if RST receivable is included in line 2 or cash balances line 1)

(10) Retail Sales Tax Payable

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

TOTAL LIABILITIES

(11) TOTAL LIABILITIES

NET TRUST POSITION

(12) NET TRUST POSITION

B.MEMBER'S CURRENT POSITION

CURRENT ASSETS

Cash on hand and bank balances in general accounts

(13) Cash on hand and bank balances

Investments other than trust investments

(14) Investments other than trust investments

Accounts Receivable

Direct Bill Commission Receivable

(15) Direct Bill Commission Receivable

Other Receivables

(16) Other Receivables

Premiums receivable over 90 days

(17) Premiums receivable over 90 days

Total Accounts Receivable

(18) Total Accounts Receivable

Due from trust account

(19) Due from trust account

Other current assets

(20) Other current assets

TOTAL CURRENT ASSETS

(21) TOTAL CURRENT ASSETS

CURRENT LIABILITIES

Bank overdraft

(22) Bank overdraft

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

Demand loans

(23) Demand loans

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

Notes payable

(24) Notes payable

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

Current position of long term debt

(25) Current position of long term debt

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

Accounts payable (other than premiums)

(26) Accounts payable (other than premiums)

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

Other current liabilities

(27) Other current liabilities

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

TOTAL CURRENT LIABILITIES

(28) TOTAL CURRENT LIABILITIES

NET CURRENT POSITION

(29) NET CURRENT POSITION

C. MEMBER'S EQUITY (Either C.1 or C.2 must be completed)

1. PROPRIETORSHIP OR PARTNERSHIP TOTAL EQUITY

(30) PROPRIETORSHIP OR PARTNERSHIP TOTAL EQUITY

2. INCORPORATED MEMBER

Paid-up share capital at reporting date

(31) Paid-up share capital at reporting date

Shareholder contribution - other

(32) Shareholder contribution - other

Retained earnings (deficit) at reporting date

(33) Retained earnings (deficit) at reporting date

Loans from shareholders at reporting date

(34) Loans from shareholders at reporting date

Loans to shareholders at reporting date

(35) Loans to shareholders at reporting date

THIS IS AN AUTOMATICALLY CREATED NEGATIVE NUMBER, DO NOT ENTER SPECIAL CHARACTERS " - " OR " () " AS IT WILL AFFECT THE TOTAL IN THE NEXT FIELDS

TOTAL EQUITY (DEFICIENCY)

(36) TOTAL EQUITY (DEFICIENCY)

Based upon the above information, you have a deficiency of:

Please contact RIBO to provide details on how this will be resolved.