Any contact subsequently made is subject to the laws of the Province of Ontario; Canada; and any insurance services offered comply with the Insurance Act, R.S.O., 1990, c1.8.

Quotation Consent Form

I acknowledge that Van Dyk Insurance Brokers Ltd. (known as the "Broker") has been retained to acquire a premium quotation and/or Consulting Services for myself (known as the "Prospect") or named individuals in addition to myself .

As part of the process I hereby authorize the Broker to collect, use and disclose personal information of myself and/or such individuals as required and as permitted pursuant to relevant privacy laws or other laws.

I hereby expressly consent to the Broker collecting, using or disclosing personal information of myself and/or such individuals, or providing such personal information to third parties as required, including insurance companies. Where there are individuals in addition to myself, or where the Prospect is a commercial or other entity, the Prospect hereby covenants and warrants that the Prospect has obtained the appropriate consent from all of the insured individuals to disclose their personal information to the Broker for these purposes accordingly.

By clicking "I Agree" I acknowledge that I have read and agree to these terms.