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09:00 – 17:00

Monday to Friday

Mississauga,

Ontario, L5J 2V8

905-822-9660

877-593-2847

Welcome to J. W. Davis Insurance Brokers Ltd. servicing the community since 1936.

April 2, 2020

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09:00 – 17:00

Monday to Friday

Mississauga,

Ontario, L5J 2V8

905-822-9660

877-593-2847

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Contact Us

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About
Insurance Quotes
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Contact Us

Auto Insurance Quote

February 15, 2016by jarekn

Auto Quote

Step 1 of 4

25%

NAME(S) ON REGISTRATION:*
First Last
CONTACT #
TELEPHONE NUMBER:*
E-MAIL:*
ADDRESS WITH UNIT # (IF APPLICABLE):*
Street Address Address Line 2 City Province Postal Code
EFFECTIVE / RENEWAL DATE:*
NAME OF CURRENT / LAST INSURANCE COMPANY AND POLICY # :
NUMBER OF YEARS WITH CURRENT COMPANY:

CANCELLED FOR NON-PAYMENT IN LAST 3 YEARS?
DATE:*
SUSPENDED / LOST LICENSE IN LAST 6 YEARS?
DATE:*
MONTHS*
MARITAL STATUS:*
DATE OF BIRTH:*
DATE OF LICENSE:
G1 (MM/YYYY) G2 (MM/YYYY) G (MM/YYYY)
DRIVERS TRAINING WITHIN LAST 3 YEARS?*
DATE:*

EXACT YEAR / MAKE / MODEL OF VEHICLE:*
(e.g. 2DR, 4DR, LE, SE, XLT, SINGLE CAB, TWIN CAB, 2WD, AWD)
IS VEHICLE LEASED OR FINANCED?
DATE VEHICLE WAS PURCHASED?*
PURCHASE PRICE?*
Coverage
COVERAGES:*
COLLISION*
COMPREHENSIVE*
RENTAL CAR COVERAGE:
DO YOU USE YOUR VEHICLE TO CARPOOL?
DO YOU PARTICIPATE IN ANY RIDESHARING PROGRAMS (SUCH AS UBER OR TURO)?
USE OF VEHICLE:
NUMBER OF KMS ONE WAY:
ANNUAL KMS:*
VIOLATIONS / TICKETS?*
PLEASE GIVE DATES AND DETAILS*
ACCIDENTS / CLAIMS?
PLEASE GIVE DATES AND DETAILS, INCL NOT-AT-FAULT, THEFT OR WINDSHIELD CLAIMS*

ARE YOU INTERESTED IN A HOME/CONDO/TENANT QUOTE?*
THE HOME / APARTMENT INSURED WITH THE SAME CARRIER?*
WHAT IS THE NAME OF THE HOME CARRIER?*
FULL NAME OF PERSON OR ORGANIZATION WHO REFERRED J. W. DAVIS INSURANCE BROKERS?
NOTES:

J. W. Davis Insurance Brokers LTD

We are offering standard and most specialty general insurance. Based in Mississauga but reaching Province wide, our goal is to cater to and tailor our clients insurance to their specific needs.

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