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McFarlan Rowlands

Medallion May 6K Community Giveaway -

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Motorcycle Insurance Quote

Please have the following on hand:

Year, make, model of vehicle to be quoted
Driving records, license and claim information

Step 1 of 4

25%

Full Name*
Street Address*
City*
Province*
Postal Code*
Date of Birth*
Driver's Licence Number*
COVERAGES REQUESTED
- Liability
- Collision
- Comprehensive
How did you hear about us?*
IF YOU WERE REFERRED TO A SPECIFIC BROKER HERE, PLEASE PROVIDE THEIR NAME:
Preferred method of contact*
Phone*
Email Address*

Profession
Occupation
Do you currently belong to a professional association?
Untitled

Vehicle Details
Vehicle Year
Vehicle Make
Vehicle Model
VIN Number (if possible)
PURCHASE DATE
MM slash DD slash YYYY
VALUE OF VEHICLE
CC OF VEHICLE
PRIMARY USE*
Total Kilometres Driven Annually
Second Vehicle
Vehicle Year
Vehicle Make
Vehicle Model
VIN Number (if possible)
PURCHASE DATE
MM slash DD slash YYYY
PRIMARY USE*
Total Kilometres Driven Annually
Total Kilometres Driven to Work (One way)
Do you have winter tires?

Your History
Date of Completion of M1
Date of Completion of M2
Date of Completion of M
Have you completed Driver Training?
Have you been issued any tickets in the past 3 years?
Year of Ticket:
TYPE OF TICKET
- Speeding
- Distracted Driving
- Impaired Driving
- Careless Driving
- Minor Traffic Violation
- Failure to have Insurance Card
Have you had any accidents in the past 10 years?
Were you at fault or not at fault?
Date of accident
Has your licence ever been suspended?
Reason for licence suspension
Date of Licence Suspension
Length of Licence Suspension
Have you ever been cancelled for insurance non-payment?
Date of Cancellation
For how long did your insurance lapse, if at all?
How many years have you been continuously insured with the same insurance company?
Start date of your next policy (MM/DD/YYYY)
Do you have a second driver?
Date of Completion of M1
Date of Completion of M2
Date of Completion of M
Have you completed Driver Training?
Have you been issued any tickets in the past 3 years?
Year of Ticket:
TYPE OF TICKET
- Speeding
- Distracted Driving
- Impaired Driving
- Careless Driving
- Minor Traffic Violation
- Failure to have Insurance Card
Have you had any accidents in the past 10 years?
Were you at fault or not at fault?
Date of accident
Has your licence ever been suspended?
Reason for licence suspension
Date of Licence Suspension
Length of Licence Suspension
Have you ever been cancelled for insurance non-payment?
Date of Cancellation
For how long did your insurance lapse, if at all?
How many years have you been continuously insured with the same insurance company?
Start date of your next policy (MM/DD/YYYY)
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McFarlan Rowlands
Doing Business with Us

1-519-579-5440 medallioninfo@mcfr.ca

604 Belmont Avenue West
Kitchener Ontario
N2M 1N5

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