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.
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