Joseph Kovacs Insurance Brokers - Other Vehicle Quote Form

Kovacs Insurance

OTHER VEHICLE INSURANCE
QUOTE FORM

To receive a quote for other vehicle insurance please complete the following form and one of our brokers will contact you as soon as possible.
(Ontario residents only please.)

Contact Information:

Name:
Street Address:
City:
Postal Code:
Phone Number:
Fax Number:
E-mail:
Vehicle Information:
Vehicle Type:
If Other, describe:
Year:
Make:
Model:
Engine Size:	cc
List Price New:	$
Sherlock Anti-Theft Engraving: Yes No
License Information:
Class of License:
Date of Level 1 Lic.:
Date of Level 2 Lic.:
Date of Level 3 Lic.:
Driver Training:	Yes No
Date of Birth:	(i.e. Sept. 19, 1965)
Insurance Information:
Coverages Required:
Deductible:	$
Liability:

Number of years licensed to operate vehicle:
(if special license required)

When should we contact you?:

How should we contact you?

E-mail Phone Fax Mail

Thank you for filling out our online quote. Please allow a few days for a response. You can now hit the submit button below to send the information or the reset button to clear the form.

JOSEPH KOVACS INSURANCE LIMITED
48 Front St. E., P.O. Box 7 Strathroy, Ontario N7G 3J

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