Member Review Council Application form - English

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* 1. Applicant contact information

First and Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Wawanesa policy number:

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* 3. How long have you been a Wawanesa policyholder for?

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* 4. Are you a Wawanesa policyholder in good standing (i.e., no arrears)?

Yes

No

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* 5. Who is your insurance broker for your Wawanesa policy?

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* 6. Please enter your insurance broker's contact information:

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* 7. What is your occupation?

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* 8. Why are you interested in volunteering on the council?

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* 9. What skills and/or experience would you bring to the council?

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* 10. Have you served on a board or panel before? If yes, please describe.

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* 11. What does fairness mean to you?

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* 12. Are you interested in being a council chair or co-chair?

Yes

No

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* 13. Please provide three references that can attest to your character and/or previous experience.

Reference 1

Reference 2

Reference 3

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* 14. Do you use assistive technologies on a daily or near-daily basis?

Yes

No

I'm not sure

If you answered 'Yes' please specify what assistive technologies you use:

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* 15. Signature - please type your name

Thank you for submitting your Member Review Council application form. Successful applicants will be contacted.