*OLOA Application

Please fill out this Application Form to join the OLOA or to update your information A yearly Membership is $275.00 Pay by e-transfer to info@oloa.ca

Trade Name

Enter the Company Name that your customers use

Legal Name

This is the officially registered Legal Name of your company - it may not be the same as your Trade Name

Contact First Name

The First Name of the contact person for your Company - this name will appear on the OLOA Website

Contact Last Name

The Last Name of the contact person for your Company

Street Address

Community

City/Town your company is located in

Prov/State

Select from below dropdown options - Enter another value if your Province or State is not there

Postal/Zip

Country

Select from dropdown list

Service Provided

Select what type of service your company provides

Phone (Company)

This would be your Company's main phone number for Customers

Email (Company)

This would be your Company's main email for Customers

Phone (Direct to Contact)

This would be a Phone Number to reach you directly - it would be used on the OLOA Website

Email (Direct to Contact)

This would be the Email to reach you directly - it would be used on the OLOA Website

Company Website

Your Company Website if you have one

Payment Method

Select from the list below

Cheque
e-transfer

Year (Application is for)

Insurance Broker

Select the Insurance Broker from list below. We will notify them that you are a paid member of OLOA. Enter an Insurance Broker below if your Insurance Broker is not in the list

New Insurance Brokerage Firm

Add name of new Brokerage Firm (the Broker Rep name goes below)

Broker Rep

Select your broker name - if not there, add their name below

Enter New Broker's Name Here

Enter a new Insurance Broker Rep Name below (if you know your Broker's name but not their Brokerage name - enter their name here)

Do not submit passwords through this form. Report malicious form

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