D-9.2, r. 6 - Regulation respecting special brokerage in damage insurance

Schedule Disposition versions

2019-06-13

SCHEDULE I

(s. 3)

STATEMENT BY THE CLIENT TO A SPECIAL BROKER ACTING FOR AN INSURER NOT HOLDING A LICENCE IN QUÉBEC

I, the undersigned ____________________

Identification of the client

Name: ____________________

Address: ____________________

Telephone no.: ____________________

hereby declare that, in respect of the following property or other interests to be insured:

Designation and location of risks to be insured

(a) Description of the risk: ____________________

(b) Exact address of the risk: ____________________

the following insurers, holding licences in Québec

Identity of insurers that refused to grant the insurance coverage requested

(a) ____________________

(b) ____________________

(c) ____________________

have refused to grant me damage insurance applied for in the amount of

Amount of insurance applied for $__________.

IMPORTANT

Furthermore, I hereby state that I was notified by the broker that:

(a) the insurer with which the risk is to be placed does not hold a licence in Québec;

(b) said insurer does not have an establishment in Québec;

(c) said insurer is not subject to supervision by the Autorité des marchés financiers and does not file the statements and reports prescribed under the Insurers Act (chapter A-32.1);

(d) said insurer is not required to maintain sufficient reserves to guarantee its obligations toward its insurers in Québec.

IN WITNESS WHEREOF, I have signed this statement,

in: ____________________ on: ____________________

______________________________

(Client’s signature)

(In the case of a legal person, the signature of its duly authorized representative)

______________________________

(Witness)

O.C. 833-99, Sch. I.

2012-09-01

SCHEDULE I

(s. 3)

STATEMENT BY THE CLIENT TO A SPECIAL BROKER ACTING FOR AN INSURER NOT HOLDING A LICENCE IN QUÉBEC

I, the undersigned ____________________

Identification of the client

Name: ____________________

Address: ____________________

Telephone no.: ____________________

hereby declare that, in respect of the following property or other interests to be insured:

Designation and location of risks to be insured

(a) Description of the risk: ____________________

(b) Exact address of the risk: ____________________

the following insurers, holding licences in Québec

Identity of insurers that refused to grant the insurance coverage requested

(a) ____________________

(b) ____________________

(c) ____________________

have refused to grant me damage insurance applied for in the amount of

Amount of insurance applied for $__________.

IMPORTANT

Furthermore, I hereby state that I was notified by the broker that:

(a) the insurer with which the risk is to be placed does not hold a licence in Québec;

(b) said insurer does not have an establishment in Québec;

(c) said insurer is not subject to supervision by the Autorité des marchés financiers and does not file the statements and reports prescribed under the Act respecting insurance (chapter A-32);

(d) said insurer is not required to maintain sufficient reserves to guarantee its obligations toward its insurers in Québec.

IN WITNESS WHEREOF, I have signed this statement,

in: ____________________ on: ____________________

______________________________

(Client’s signature)

(In the case of a legal person, the signature of its duly authorized representative)

______________________________

(Witness)

O.C. 833-99, Sch. I.