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Car
Home
Business
Farm
Groups
Life & Investments
Mental Health
Gold Private Client
Get A Quote
Business Insurance Quote
Industry
*
INDUSTRY TYPE*
Agriculture
Contractor/ Construction
Garage
Healthcare
Hospitality/ Restaurant
Investment Property
Manufacturing
Professional Services
Retail
Service Business
Student Rental Property
Other
Description of Business
*
Number of Employees
*
NUMBER OF EMPLOYEES*
0-9
10-49
50-249
250+
Business Name
*
Operating Name
*
Business Location Address
Address Line 2
City
Province
Multiple Locations
What has brought you to us today?
*
WHAT HAS BROUGHT YOU TO US TODAY?*
Already have insurance, looking for better deal
Referral
I am an existing client
I was referred by / am a Medallion member
I was referred by / am a Magenta client
Contract requirement or association / college requirement
Exploring options, need in next month
Exploring options, need later than one month from now
Looking to speak with a professional to discuss details and get advice
Need for school project
IF YOU WERE REFERRED TO A SPECIFIC BROKER HERE, PLEASE PROVIDE THEIR NAME:
OFFICE LOCATION AND/OR BROKER NAME
Who were you referred by?
When does your policy renew?
Contact Info
Contact Name
*
Preferred Method of Contact
*
PREFERRED METHOD OF CONTACT*
Email
Phone
Email
*
Phone
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Phone
This field is for validation purposes and should be left unchanged.
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