EmailMe Form - Broker Contract Application

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10020 12th Avenue, North Battleford SK S9A 3A4
Toll-Free Phone: 1-866-979-2747
Email: oasiscontracts@oasisins.ca

Brokerage Legal Name *

Brokerage Operating Name (if different than Legal Name)

Main Brokerage Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Brokerage Phone Number *

### - ### - ####

Brokerage Office Email *

Multiple branches

Yes, we have multiple branches

Who is the main contact for the contract? *

First Last

Email *

What Provinces are you licensed for? Provide license numbers.

British Columbia
Alberta
Saskatchewan
Manitoba
Nova Scotia
New Brunswick

List any additional provinces and licenses not listed above (if applicable)

Has the Brokerage or any Employees ever been suspended, terminated or fined by any Insurance Regulator, Insurer, Insurance Council in the last 10 years? *

Yes

No

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