Position Reports

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

Name(Required)

First Last

Email(Required)

Firm Name(Required)

Firm Address(Required)

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

Firm Registration 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)

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

(2)

Less premiums over 90 days

(3)

Allowable premiums receivable

(4)

Investments held in trust as allowed by Regulation

(5)

Total Assets

(6)

LIABILITIES

Insurance premiums payable

(7)

Prepaid premiums

(8)

Refunds due to insureds

(9)

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

(10)

TOTAL LIABILITIES

(11) TOTAL LIABILITIES

NET TRUST POSITION

(12)

B.MEMBER'S CURRENT POSITION

CURRENT ASSETS

Cash on hand and bank balances in general accounts

(13)

Investments other than trust investments

(14)

Accounts Receivable

Direct Bill Commission Receivable

(15)

Other Receivables

(16)

Premiums receivable over 90 days

(17)

Total Accounts Receivable

(18)

Due from trust account

(19)

Other current assets

(20)

TOTAL CURRENT ASSETS

(21)

CURRENT LIABILITIES

Bank overdraft

(22)

Demand loans

(23)

Notes payable

(24)

Current position of long term debt

(25)

Accounts payable (other than premiums)

(26)

Other current liabilities

(27)

TOTAL CURRENT LIABILITIES

(28)

NET CURRENT POSITION

(29)

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

1. PROPRIETORSHIP OR PARTNERSHIP TOTAL EQUITY

(30)

2. INCORPORATED MEMBER

Paid-up share capital at reporting date

(31)

Shareholder contribution - other

(32)

Retained earnings (deficit) at reporting date

(33)

Loans from shareholders at reporting date

(34)

Loans to shareholders at reporting date

(35)

TOTAL EQUITY (DEFICIENCY)

(36)

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

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