Request a quote – Branch Referral "*" indicates required fields What product does the client need a quote for?* Personal insurance Business insurance Private client services (high net worth personal lines) Employee benefits Group retirement Life and disability insurance What product(s) is the client interested in?* Auto House Townhome Mobile home Condo Tenant Cottage and cabin Home - under construction Contents in storage Motorcycle RV Travel Marine and boat Which of the following best describes the client’s situation?* They own the home They rent the home They own and rent out the home It's vacant What industry is the client's business?* Professional services Construction & Contracting Education Faith-based organization Farm & Agriculture Forestry Healthcare Hospitality Manufacturing Not-for-profit Oil & Gas Real Estate/Building Owner Recreation Retail/Wholesale Social Services Transportation & Logistics Wineries Welding Other Describe the business operations* Does the client currently carry insurance with Westland?* Yes No Client reference number on most recent Westland invoice (optional) What product(s) does the client currently have with Westland?* Auto Condo House Tenant General Liability Professional Liability Cyber Commercial Auto Commercial Property Other Please specify* Client record is in Acturis?* Yes No Acturis client link(s)*Does the client have an existing plan with another broker?* Yes No HiddenWhat product(s) does the client have with another broker? Employee benefits Group retirement Renewal date* MM slash DD slash YYYY Does the client have an existing commercial policy with another broker?* Yes No What product(s) does the client have with another broker?* General Liability Professional Liability Cyber Commercial Auto Commercial Property Other Describe the business operations* Renewal Date (Optional) DD slash MM slash YYYY Client's informationFirst name* Last name* Date of birth* MM slash DD slash YYYY Title* Company* # of full-time employees*1-1011-5051-200201-500500+Phone*Email* Preferred contact method* Phone Email HiddenSection BreakProvince*Choose your ProvinceAlbertaBritish ColumbiaNew BrunswickNewfoundland and LabradorManitobaNova ScotiaOntarioPrince Edward IslandSaskatchewanAddress Street Address Address Line 2 City ZIP / Postal Code Prior insurance informationPolicy details*Policy #CarrierPremium Add RemoveExpiry / renewal date* MM slash DD slash YYYY Reason for changing brokersPrevious losses or open claims* Yes No Details*HiddenPersonal/BusinessHas the client had any personal insurance claims in the last 5 years?* Yes No Has the client had any business insurance claims in the last 5 years?* Yes No Please provide the following information for each loss or claim in the past 5 years:*Date of loss or damageCause or origin of loss or damageTotal amount of claim $ Add RemoveHas any insurer cancelled or declined to renew any of the client's policies (PL or CL)?* Yes No Please provide the following if you have had a policy cancelled, non-renewed or you were refused insurance.Date of cancellation, non-renewal, or refusalReason or circumstances for the cancellation, non-renewal, or refusal: Add RemoveHiddenAdditional informationAdditional information (Optional)Referring brokerReferring entity*WestlandBMTCalowDupuis LangenFront RowHubbardMaxwellMontridgePrimeSigurdsonWinchAdvisor's Name* Advisor's Email* Branch*First ChoiceSecond ChoiceThird ChoiceHead Office Department*CommercialOnline AutoSelect Client ServicesCAPTCHA
