Letter of Broker of Record Appointment
To: J.D. Smith Insurance Brokers (1-800-917-SAVE):

I am a current Kingsway Insurance Motorcycle Insured.
I wish to have my policy issued through your office at renewal.
Please give me ALL THE AVAILABLE DISCOUNTS.
The completion and submission of this form will serve to appoint J.D. Smith Insurance Brokers Inc. as my Broker of Record from today.
You can email this form, but we ALSO need it signed and faxed to us at 905-764-9618 so we can make changes and get you the best rate available.

Date:

Kingsway Policy Number:

Your Policy Renewal Date:

Name:

Address:

City:

Province:

Postal Code:

Home Phone #:

Work Phone #:

Email:

 

Before submitting this form, please enter the information, then print the page, sign below and fax it to 905-764-9618.

Signature: __________________________________________

 
 
 
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