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McFarlan Rowlands
About Us
News & Blog
Make a Claim
For Associations
MyMedallion Login
Car
Car Insurance
Motorcycle Insurance
Recreational Vehicles
Classic Car Insurance
Boat Insurance
Sport Vehicle Insurance
Home
Home Insurance
Condominium Insurance
Tenant Insurance
Second Home / Cottage Insurance
Rental Property Insurance
Other
Contact Us
Get a Quote
Step
1
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4
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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?
*
HOW DID YOU HEAR ABOUT US?*
Family or Friend
Online Advertising
Social Media
I am an existing client
Billboard
Google
Spotify
Other
IF YOU WERE REFERRED TO A SPECIFIC BROKER HERE, PLEASE PROVIDE THEIR NAME:
Preferred method of contact
*
PREFERRED METHOD OF CONTACT*
Email
Phone
Phone
*
Email Address
*
Profession
PROFESSION
Police
Fire
Paramedic
Other
Not a First Responder
Occupation
Do you currently belong to a professional association?
DO YOU CURRENTLY BELONG TO A PROFESSIONAL ASSOCIATION?
Yes
No
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
Your History
Have you been issued any tickets in the past 3 years?
HAVE YOU BEEN ISSUED ANY TICKETS IN THE PAST 3 YEARS?
No
Yes
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?
ANY ACCIDENTS IN THE PAST 10 YEARS?
No
Yes
Were you at fault or not at fault?
WERE YOU AT FAULT OR NOT AT FAULT?
At fault
Not at fault
Date of accident
Has your licence ever been suspended?
HAS YOUR LICENCE EVER BEEN SUSPENDED?
No
Yes
Reason for licence suspension
REASON FOR LICENCE SUSPENSION
Medical Reason
Suspension due to a conviction
Suspension due to driving under the influence
Other
Date of Licence Suspension
Length of Licence Suspension
LENGTH OF LICENCE SUSPENSION
3 Days
30 Days
60 Days
1 Year
Have you ever been cancelled for insurance non-payment?
HAVE YOU EVER BEEN CANCELLED FOR INSURANCE NON-PAYMENT?
No
Yes
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)
CAPTCHA
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