Personal Information Privacy and Electronic Document Act (PIPEDA) Consent
This form collects personal contact information so that we may correspond with you and provide the results of your quotation. It also may collect underwriting information about your automobile, property, driving record, claims history, etc. This information is required by the insurance company to provide a rate for insurance coverages. It may be submitted to an insurance company for the single purpose of obtaining a quote. I give consent for the information provided in this form to be used by Pacific Insurance Broker Inc and its representatives.