fbpx

Quote Form Test

Get a Quote - Auto Stepped
Have you had any cancellations, accidents, tickets, or gaps in insurance in the last 6 years? *
Address *
Address
City
Province
Postal Code
Do you own a home or rent? *

As your broker, I am gathering this consent on behalf of the insurer who advises me that: in respect of this quotation/application, any policy we issue and subsequent renewals or changes, we may collect, use, and disclose personal information reports including policy history, claims history, investigative information, rating information, risk information and only with respect to you, your personal credit information including credit score, as permitted by law and in accordance with our privacy policies.

Do you, and on behalf of others listed, authorize use to collect, use, and disclose to appropriate third parties, including your broker, this information solely relating to your personal property policy for the purposes necessary to assess the risk, determine a premium, determine eligibility and conditions for a premium payment plan, investigate and settile claims, analyze business results and detect and prevent fraud?

Do you agree with the following consent statement? *
×

Please contact our office to speak with a representative at 1-866-466-9660