LGL54 (102019) Strategic Alliance Application Form Page 2 of 2
Financial Institution Information
Please submit a void cheque for direct deposit to your account.
The Supplier hereby directs ICBC to make any and all payments due and owing to the Supplier by way of electronic transfer of funds to the
following account:
BANK NAME
BANK ADDRESS (street/city/province/postal code)
NAME ON ACCOUNT
BANK TRANSIT NUMBER BANK NUMBER BANK ACCOUNT NUMBER
EMAIL ADDRESS (for bank deposit notication — if different than above)
The Supplier understands that should a payment be returned to ICBC then ICBC will make payment by the way of cheque to the Supplier
until the Supplier directs ICBC in writing to make payments into a valid and existing account.
Privacy Checklist of Personal Information*
Yes No Section 30.1 of FIPPA — Storage & Access in Canada
Does the facility store, access or disclose personal information (arising from, connected with, or related to an ICBC
claim) outside of Canada?
If yes, provide the country where information is stored, and the name of the data management company.
COUNTRY WHERE DATA IS STORED DATA MANAGEMENT COMPANY NAME
Section 30 of FIPPA — Protection of Personal Information
Are the customers’ les stored in a secure environment (inaccessible from the public)?
Are the hard or electronic copies of les stored in a secure area onsite?
If no, then please explain where the information is being stored.
Are the customers’ les left unattended and accessible/viewable by the public?
Is customer’s personal information* displayed in public areas (white/chalk board, le folders)?
Is customer’s personal information* viewable and accessible by the public on a computer screen?
Are user ID’s and passwords protected from view or access to the public?
* personal information includes: Drivers licence, Credit or Bank Card information, Customer name(s), addresses and phone numbers
Personal information on this form is collected pursuant to section 26 of the Freedom of Information and Protection of Privacy Act and is
used for the purpose(s) of processing applicant information. Information is collected, used and disclosed in accordance with the Freedom
of Information and Protection of Privacy Act. Should you have any questions about the collection of information, please email
CLS-SpecialCounsel@icbc.com.
I acknowledge and agree that I am an independent contractor, and am not an agent, employee or partner of ICBC. I am responsible
for making all required statutory remittances, including those under the Income Tax Act, Employment Insurance Act, and Workers
Compensation Act. ICBC has made no representations or warranties to me as to the volume of referrals or work I might receive, if any,
and I acknowledge that obtaining a Supplier Account is no guarantee of work.
APPLICANT’S SIGNATURE DATE
