This form is also available in pdf format if you prefer not to complete the quote form online.
*
Please note...
This
DOES NOT
constitute a report of your claim!
You MUST contact KW Insurance Brokers either by phone (519) 744-4190, or in person at our office located at 501 Krug Street in Kitchener.
If it is after business hours, please call the applicable
emergency number
for your company.
Your Insurance Information:
Company:
Policy Number:
Insured:
Name:
Street:
Telephone:
(H)
(W)
City:
ONTARIO
Postal Code:
Injured:
Name:
Address:
Telephone:
(H)
(W)
Injured Location:
Pedestrian
Ins Veh
Oth Veh
Extent of Injury:
Age:
years
Name:
Address:
Telephone:
(H)
(W)
Injured Location:
Pedestrian
Ins Veh
Oth Veh
Extent of Injury:
Age:
years
Witnesses:
Name:
Telephone:
(H)
(W)
Address:
Witness Location:
Pedestrian
Ins Veh
Oth Veh
Name:
Telephone:
(H)
(W)
Address:
Witness Location:
Pedestrian
Ins Veh
Oth Veh
Your Insured Vehicle:
Plate Number:
Owner's Name:
Owner's Address:
Driver's Name:
Check here if same as owner:
Driver's Name:
Driver's Address:
Driver's License Number:
Prov.
:
Date of Birth:
(dd/mm/yy)
Purpose of Use:
Used with Permission:
Yes
No
Describe Additional Damage:
Where can the vehicle be seen?
Is Vehicle Driveable?
Yes
No
Other Party:
Auto Damage:
Year:
Make:
Model:
License Plate Number:
Owner's Name:
Owner's Address:
Telephone:
(H)
(W)
Driver's Name:
Check here if same as owner:
Driver's Name:
Driver's Address:
Telephone:
(H)
(W)
Insurance Company:
Policy Number:
Additional Information:
Enter the text shown on image above
KW Insurance Brokers
O/B 1216592 ON LTD
501 Krug St. (Krug St. Plaza), Kitchener, ON N2B 1L3
Telephone: (519) 744-4190 Fax: (519) 744-7664
Website:
www.kwbroker.ca
