Van Dyk Insurance Brokers Ltd. - The Right Choice
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Request For A Quotation

(Ontario Residents Only)

Note: Fields marked in red are required.

Disclaimer: Submission of a request for quotation form does not constitute a policy or binder of insurance, nor does it obligate Van Dyk Insurance Brokers Ltd. to place or bind insurance coverage or to generate a quotation. Coverage will only be bound when all the applications, forms, deposit monies, and required documentation have been properly signed and acknowledged as being received by the broker. Only then will a temporary binder be issued by the broker.

Submission of a quotation request form does not establish an "agent and principal" relationship between the broker and the "prospect", nor does it obligate the prospect to purchase insurance from the Broker.

Number of errors: 0.

General Information
Full Name:
Postal Code:
Must be in this format: A#A#A#
Street name and number:
Phone Number:
Must be in this format: ###-###-####
Email address:
Date you would like the coverage to start:
Must be in this format: yyyy/mm/dd
Name of previous insurer:
Policy number:
Was this policy cancelled for non-payment? Yes   No
Any licence suspensions in the last 6 years? Yes   No
Has any insurance company cancelled you in the last 3 years? Yes   No
Vehicle Information
Vehicle #1 Vehicle #2
VIN
Will this vehicle be used to drive to work/school/go-station? Yes   No Yes   No
How far will you be commuting to work/school/go-station?
Vehicle #1:
Vehicle #2:
Will this vehicle be used for business? Yes   No Yes   No
How many kilometers do you drive per year?
Do you own or lease the vehicle?
Name of leinholder
Address
(Street # and Name)
Name of lessor
Address of lessor
Coverage
Would you like collision? Yes   No Yes   No
How much collision deductable would you like?
Vehicle #1:
Vehicle #2:
Would you like comprehensive? Yes   No Yes   No
How much comprehensive deductable would you like?
Vehicle #1:
Vehicle #2:
Liability amount
Driver Information
Driver(s) Information:
Driver #1 Driver #2
Name:
Sex:
Martial Status:
Licence Number:
Date of G2: (yyyy/mm)
Date of G: (yyyy/mm)
Driving Ed.:
Has there been a lapse of coverage for non-payment? Yes   No
Has there been a lapse of coverage for another reason? Yes   No
 

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19 Royal Oak Drive, Brantford, Ontario, N3R 7P2, Canada
Phone (519) 758-1700
Toll-free (800) 437-9555