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

To proceed with a Brokerage Amalgamation Request you must fill out the Amalgamation Checklist and attach the required documents in order to proceed. The amalgamation will not be processed until this is completed and all applicable attachments are received.

Full Name of New Amalgamated Brokerage*

Is this a legal name change?*

If there was a legal name change as a result of an amalgamation, please upload a Principal Broker Undertaking and updated Position Report.

Please upload the Principal Broker Undertaking.*

Max. file size: 256 MB.

Please upload the Updated Position Report.*

Max. file size: 256 MB.

Legal Name of Principal Broker of New Firm*

First Last

Registration Number of Principal Broker*

Email Address*

Phone Number

Ontario Mailing Address For Service of Documents*

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

Please attach Articles of Amalgamation*

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Max. file size: 256 MB.

Do you intend to use a trade name?

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Certificate of Registration (formerly referred to as a Masters Business License) for any registered trade names under the Business Names Act*

Yes

Please attach the Certificate of Registration (formerly Masters Business License).*

Drop files here or

Max. file size: 256 MB.

Updated Certificates of Mandatory Insurance (Regulation 991, Section 20) both indicating that the RIBO Endorsement applies and the firm’s new legal name (must include trade names)*

1) Errors and Omissions Insurance of at least $3,000,000 in coverage, $6,000,000 aggregate

2) Fidelity Bond of at least $100,000 in coverage

Please attach Errors and Omissions Insurance of at least $3,000,000 in coverage, $6,000,000 aggregate*

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Max. file size: 256 MB.

Please attach Fidelity Bond of at least $100,000 in coverage*

Drop files here or

Max. file size: 256 MB.

How many brokerages are being amalgamated?*

Brokerage being amalgamated*

Registration Number

Effective Date

Check if Deregistered*

Deregistered

Brokerage being amalgamated*

Registration Number

Effective Date

Check if Deregistered*

Deregistered

Brokerage being amalgamated*

Registration Number

Effective Date

Check if Deregistered*

Deregistered

Brokerage being amalgamated*

Registration Number

Effective Date

Check if Deregistered*

Deregistered

Brokerage being amalgamated*

Registration Number

Effective Date

Check if Deregistered*

Deregistered

Do you have tail coverage?

Please attach the proof of tail coverage

Max. file size: 256 MB.

Deregistration

To deregister any firm, we require the following as confirmation from the Principal Broker of the registered entity:

Confirm that all the individuals/employees are no longer affiliated with the firm*

Confirm that all servicing of the book of business including endorsements and cancellations are transacted and issued under the firm.*

All trust obligations (to insurers, insureds, etc.) have been fulfilled.*

Tail coverage has been secured for the firm’s E&O policy (attach proof of Tail cover , including a copy of the lead firm’s E&O that lists all amalgamated firms)*

Amalgamated Brokerage*

Please Confirm the name and registration number of the Firm that you are seeking to deregister as a result of the amalgamation*

Name Registration Number

Deregistered Brokerage #2

Confirm that all the individuals/employees are no longer affiliated with the firm*

Confirm that all servicing of the book of business including endorsements and cancellations are transacted and issued under the firm.*

All trust obligations (to insurers, insureds, etc.) have been fulfilled.*

Tail coverage has been secured for the firm’s E&O policy (attach proof of Tail cover , including a copy of the lead firm’s E&O that lists all amalgamated firms)*

Amalgamated Brokerage*

Please Confirm the name and registration number of the Firm that you are seeking to deregister as a result of the amalgamation*

Name Registration Number

Deregistered Brokerage #3

Confirm that all the individuals/employees are no longer affiliated with the firm*

Confirm that all servicing of the book of business including endorsements and cancellations are transacted and issued under the firm.*

All trust obligations (to insurers, insureds, etc.) have been fulfilled.*

Tail coverage has been secured for the firm’s E&O policy (attach proof of Tail cover , including a copy of the lead firm’s E&O that lists all amalgamated firms)*

Amalgamated Brokerage*

Please Confirm the name and registration number of the Firm that you are seeking to deregister as a result of the amalgamation*

Name Registration Number

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Please attach letter confirming that all trust obligations for the above-noted firm(s) have been fulfilled and that they have been deregistered with RIBO.

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Max. file size: 256 MB.

Have you completed the Broker Amalgamation Template?*

Yes

Please download and fill out the Broker Amalgamation Template (template will automatically download when link is clicked). This must be attached with your request in order for RIBO to process the amalgamation.

Please attach completed Broker Amalgamation Template*

Drop files here or

Max. file size: 256 MB.

What is the firm's fiscal year end date?*

Will the brokerage use a shareholder loan to meet the equity requirement ?*

If you are using a shareholder loan to meet the equity requirement The Position Report must indicate Equity in the business of at least $5,000 in the case of a Corporation OR IN ANY CASE such higher amount of equity as is required to equal the SUM of the combined deductible amounts applying to the Errors and Omissions and the Fidelity bond policies. If a shareholder loan is used to meet the equity requirement this Shareholder Loan Undertaking is required to be completed and signed by all interested parties confirming that this loan will not be removed in whole or in part if such removal of funds would cause an equity shortfall and must be uploaded below.

Please upload the completed Shareholder Loan Undertaking*

Max. file size: 256 MB.

Please attach copy of trust account VOID Cheque

Max. file size: 256 MB.

Do you have an Out of Province Trust Account?

Have you filled out the Out of Province Trust Account Application?

If you have an Out of Province Trust Account, you must fill out and submit the Out of Province Trust Application, then return to this form.

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Out of Province Trust

Regarding the holding of premiums for Ontario business in a Trust Account outside Ontario, application must be made to the Qualification and Registration Committee for an exemption to do so. The Qualification and Registration Committee will require a copy of a cheque for the special trust account bearing the firm’s name and the imprint “in trust” along with the appropriate category indicated as to the amount of Ontario business by the firm.

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Legal Name of Principal Broker

First Last

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Legal Name of Amalgamated Firm

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Address of Firm

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

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• Form 1 Position Reporting – Consolidated filing Separate Ontario Trust Account must be maintained. All records may be consolidated with your total business.

Agreed

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• Form 1 Position Reporting – Ontario only trust position filing Separate Ontario Trust Account must be maintained along with books and records pertaining to Ontario Business in such a way that an Ontario trust position can be ascertained from them. The broker will be required to file their position report showing only Ontario trust information of the Form 1.

Agreed

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I being the Principal Broker of the above mentioned entity agree to comply with the requirements for holding trust monies outside the Province of Ontario and will govern myself accordingly.

Yes

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Signed (Name)

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Date

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Please confirm Registered Legal Name of Amalgamated Firm and Existing RIBO Registration number (if currently registered)*

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Please confirm the Trade Name or Operating Name Used to Deal with Public (if different from Legal

Please attach the completed Out of Province Trust Account Application*

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Max. file size: 256 MB.

Amalgamation Fee*

Price:

Credit Card

Card Details

Cardholder Name