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:
Policy Type:
Effective Date:
(dd/mm/yy)
Expiration Date:
(dd/mm/yy)
Date of Loss:
(dd/mm/yy)
Time of Loss:
A.M.
P.M.
Previously Reported:
Yes
No
Insured:
Name:
Street:
City:
Telephone:
(H)
(W)
Loss:
Location of Loss:
Street:
City:
Police or Fire Dept. to which reported:
Kind of Loss:
*
Please check all that apply.
Fire
Theft
Lightning
Hail
Flood
Wind
Other:
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
