Registration Application B - Registered Insurance Brokers of Ontario (RIBO) - Ontario's regulator of general insurance brokers"

Registration Application B

PLEASE ANSWER ALL QUESTIONS IN THE FORM BELOW:

IRIS
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Verified
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Product Type
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YES TO SPECIAL CONDITIONS - PLEASE CONTACT WITHIN 3 BUSINESS DAYS
Before We Get Started
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Have you completed your Criminal Record Check?*
- Yes
- No
You will be required to complete a Criminal Record Check from your local police department or through Sterlingbackcheck (Please note that we do not accept third party checks).
Have you completed a Criminal Record Check from your local police department, or through Sterlingbackcheck?*
You will be required to complete a Criminal Record Check from your local police department or through Sterlingbackcheck (Please note that we do not accept third party checks).
Please do not proceed any further until you have completed your Criminal Record Check. A Criminal Record Check is a requirement for registration.
Please visit Sterling Backcheck to conduct your Criminal Record Check, then return to this form.
Please select the option below that applies to you*
Check here to certify that the criminal record verification you are attaching is LESS THAN 60 days old AND includes any and all current and previous names
Please do not proceed any further until you have obtained a Criminal Record Check verification that is LESS THAN 60 DAYS OLD and includes all current and previous names.
Please attach evidence of your criminal record verification (must be LESS THAN 60 DAYS OLD and include any and all current and previous names)*
Max. file size: 256 MB.
ATTENTION! WE DO NOT ACCEPT A RECEIPT THAT YOU HAVE APPLIED FOR A RECORD CHECK, WE REQUIRE THE ACTUAL CRIMINAL RECORD VERIFICATION.
Are you currently employed with a brokerage?*
Please confirm the date that the employment confirmation form was signed by the principal broker (bottom section of form)
MM slash DD slash YYYY

NOTE: Applicants that submit employment confirmation forms that are signed more than 10 days ago will results in delays in processing times beyond 5 - 10 business days
Please upload the completed Employment Confirmation Letter signed by the Principal Broker or Deputy Principal Broker at your sponsoring brokerage (MUST BE DATED WITHIN LAST 10 DAYS OR WILL NOT BE PROCESSED). Please ensure that your legal name is on the Employment Confirmation letter*
Max. file size: 256 MB.
If you have not completed the Employee Confirmation Letter please access the form here, fill it out and ensure it is signed by the Principal Broker or Deputy Principal Broker at your brokerage.

PLEASE NOTE: WE DO NOT ACCEPT EMPLOYMENT CONTRACTS / AGREEMENTS.

NOTE: You may need Adobe Acrobat to fill in this form. If you do not have it, download it for free here
ATTENTION! In order for your brokerage to be notified that they are to pay on your behalf, a Brokerage Payment Form MUST be filled out. The Broker Payment Form will launch automatically once you complete this form.
Please do not proceed any further until you have joined a RIBO Registered Brokerage.

Employment (sponsorship) is a requirement for registration. License candidates must find employment with a RIBO registered general insurance brokerage firm within one year of passing the examination. Please complete your application at a later date once you have secured employment.
Have you previously been registered or licensed with RIBO?*
Are you now or have you ever been registered or licensed, or applied for registration or a licence in any capacity under any act or regulation thereof, regulating “dealing in any class of insurance” of any province, territory, state,or country?“ Dealing in any class of insurance” includes selling, advising, or consulting with respect to any class of insurance.*
How many other licenses / registrations have you had?*
Jurisdiction / Regulatory Authority #1*
Confirm Date License is Valid Till*
MM slash DD slash YYYY
Please upload a copy of your license for this jurisdiction
Max. file size: 256 MB.
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Please upload a copy of your license for this jurisdication

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Max. file size: 256 MB.
Jurisdiction / Regulatory Authority #2*
Confirm Date License is Valid Till*
MM slash DD slash YYYY
Please upload a copy of your license for this jurisdiction*
Max. file size: 256 MB.
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Please upload a copy of your license for this jurisdication

Drop files here or

Max. file size: 256 MB.
Jurisdiction / Regulatory Authority #3*
Confirm Date License is Valid Till*
MM slash DD slash YYYY
Please upload a copy of your license for this jurisdiction*
Max. file size: 256 MB.
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Please upload a copy of your license for this jurisdication

Drop files here or

Max. file size: 256 MB.
Are you now or have you ever been registered, licensed or applied for registration to deal with the public OUTSIDE of the insurance industry? This would include any other profession that requires you to be licensed or hold a registration by a professional body or organization , in any capacity in any province, territory, state, or country? E.g., Mortgage, Real Estate, Car Sales, Lawyer, Accountant, etc.
Please provide details of licenses or registration and provide information if valid or when they expired (max 75 words)*
Do you certify that you have obtained an official results letter indicating a passing result on the required RIBO examination(s) and are therefore eligible to apply for a RIBO general insurance broker license? (Screenshots and photos of results will not be accepted)*
PLEASE ENSURE THAT YOUR OFFICIAL RESULTS LETTER IS IN YOUR LEGAL NAME OTHERWISE YOU WILL NEED TO OBTAIN A NEW OFFICIAL RESULTS LETTER FROM THE COURSE PROVIDER. PLEASE NOTE: OFFICIAL EXAM RESULTS ARE GOOD FOR A ONE YEAR PERIOD, SO PLEASE ENSURE THEY ARE STILL VALID.
What date was the exam written on?
MM slash DD slash YYYY
NOTE: Individuals with Insurance Institute exam results will have their applications automatically rejected if their results are less than two weeks old
Please do not proceed any further. Obtaining a pass result on the RIBO examination is a requirement for registration. Please complete your application at a later date once you have obtained a passing result on the RIBO Exam.
Please upload evidence of your exam results confirming you have passed the applicable RIBO Exam (e.g. PDF results letter or Insurance Institute exam results confirmation)*
Max. file size: 256 MB.
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Please upload evidence of your exam results confirming you have passed the applicable RIBO Exam (e.g. PDF results letter or Insurance Institute exam results confirmation)*

Drop files here or

Max. file size: 256 MB, Max. files: 6.
Contact Information
Your Full Legal Name*
First Middle Last
Do you go by any other first name other than your full legal first name? (Please select Yes or No)
Yes
No
Please provide the other First Name (This name will be added in brackets after your legal first name)*
First
Have you ever had a name change (including due to marriage)?*

No

Yes
How many previous names have you had*
Previous Legal Name(s)
First Middle Last
Please confirm name change date
MM slash DD slash YYYY
Previous Legal Name(s)
First Middle Last
Please confirm name change date*
MM slash DD slash YYYY
Previous Legal Name(s)
First Middle Last
Please confirm name change date*
MM slash DD slash YYYY
Your Personal Email*
Your Work Email
Your Mobile Number*
Work Number
Other Phone Number
Ontario Mailing Address (you must have an Ontario mailing address to register)*
e.g. "Unit 1200 - 255 Main Street" City Province Postal Code
Check "Yes" if residential (home) address is different than above*

No

Yes
Residential (Home) Address*
e.g. "Unit 10 - 4000 Queen Street West" City Province Postal Code
Date of Birth (must be 18yrs or older)*
MM slash DD slash YYYY
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Birthdate (Month and Day)*
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Day*

Pay Later / Have Brokerage Pay

Background Information
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Please confirm the brokerage and branch location (if applicable) where you will be working*

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Please confirm the brokerage address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you ever been discharged for cause?*

No

Yes
Please provide details of the discharge (i.e. Company's name, length of employment, type of discharge, specific details of reason and any action taken) (Max 75 words)*
Will you have other employment outside of being an insurance broker?*

No

Yes
Secondary Business Exemption - Please Complete in Full
Have you completed the Secondary Business Exemption form?*
Please upload a copy of your completed Secondary Business Exemption Form*
Max. file size: 256 MB.
Please obtain the Secondary Business Exemption form here. Once it is completed you may return to this form to upload it
Please attach a one page letter of request explaining in detail the secondary occupation
Max. file size: 256 MB.
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Please attach a one page letter of request explaining in detail the secondary occupation

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Max. file size: 256 MB.

Please attach a letter from the Principal Broker of your firm advising that they do not feel this activity will interfere with your insurance responsibilities and fully support your request for an exemption.*
Max. file size: 256 MB.
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Please attach a letter from the Principal Broker of your firm advising that they do not feel this activity will interfere with your insurance responsibilities and fully support your request for an exemption.*

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 256 MB.

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Have you ever pleaded guilty or been found guilty of an offence related to insurance?*

No

Yes
Please provide details of the charges along with detailed description on the circumstance surrounding the conviction*
Have you ever pleaded guilty or been found guilty of any offence not noted above?*

No

Yes
Please provide details of the charges along with detailed description on the circumstance surrounding the conviction*
Have you ever been convicted or ever been charged under any law of any Canadian province or Territory, State or Country anywhere in the world including but not limited to the following? Offences under Federal Canadian Statutes such as The Income Tax Act and the Immigration Act; All Criminal Code offences (including impaired driving); Offences for which an absolute or conditional discharge has been granted. This excludes offences for which a pardon has been granted (and not revoked) under The Criminal Records Act.*

No

Yes
Please provide details of the charges along with detailed description on the circumstance surrounding the conviction*
Have you ever been the subject of a charge or indictment?*

No

Yes
Please provide details on the charges along with a detailed description of circumstances surrounding the charges*
Have you personally,or has any business of which you are or were an officer,director,partner or controlling shareholder ever been subject to bankruptcy proceedings,consumer proposal or plan of arrangement?*

No

Yes
Please provide a brief explanation why you were in a position to claim bankruptcy and attach a long statement of affairs and copy of discharge*
Please attach your consumer proposal or plan of arrangement and a copy of your most recent Statement of Affairs along with copy of discharge*

Drop files here or

Max. file size: 256 MB, Max. files: 1.

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If your bankruptcy proceeding and/or consumer proposal is pending, please attach documentation from your Licensed Insolvency Trustee confirming your bankruptcy proceeding and/or consumer proposal is in good standing and payments are up to date

Drop files here or

Max. file size: 256 MB, Max. files: 1.

Have you ever been refused a licence or registration,or been subject to disciplinary action or Order,or are you currently under investigation by any organization or regulator in Canada or anywhere in the world?*

No

Yes
Please provide details below:*
Are there any pending legal proceedings against you or against any business of which you are an officer,director,partner or controlling shareholder in the Province of Ontario or anywhere in the world for any reason whatsoever?*

No

Yes
Please provide details below:*
Has any Judgment or Court Order ever been rendered against you personally or any business of which you were at the time an officer, director, partner or controlling shareholder in any civil or Criminal Court in the Province of Ontario or anywhere in the world for any reason whatsoever?*

No

Yes
Please attach Court Document and a written explanation of the Judgement or Court Order*

Drop files here or

Max. file size: 256 MB, Max. files: 1.

Has any Judgment or Court Order which is unsatisfied ever been rendered against you personally or any business of which you were at the time an officer,director,partner or controlling shareholder in any civil or Criminal Court in the Province of Ontario or anywhere in the world for any reason whatsoever?*

No

Yes
Please attach all Court Documents and a written explanation of the Judgement or Court Order*
Max. file size: 256 MB.

Pay Later / Have Brokerage Pay

Consent
I have read and agree to the Consent & Notification Statement and certify the following:

The undersigned individual hereby certifies that the foregoing statements are true and correct to the best of my knowledge, information and belief and hereby undertakes to notify RIBO in writing of any material change therein, within 30 days of such change, as provided by the regulations. The undersigned individual hereby further certifies that I am conversant with the provisions of the Registered Insurance Brokers Act, its Regulations and By-laws and will act in accordance with those provisions. The undersigned applicant acknowledges and consents that RIBO may obtain any information whatsoever, from any source, as permitted by law in any jurisdiction in Canada or elsewhere.

Please confirm all of the above as acknowledged and understood*

Yes, I confirm all of the above as acknowledged and understood
Your eSignature confirming all of the above*

Did you want to pay later or have your brokerage pay for your registration?*
Pay Licene Fee
Price:
Total
$ 0.00 CAD
NOTE: Payment processing may take up to 60 seconds. Please do not press Submit again.
Comments
This field is for validation purposes and should be left unchanged.

Pay Later / Have Brokerage Pay

Before We Get Started

Contact Information

Background Information

Secondary Business Exemption - Please Complete in Full

Section Break

Consent