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

I am a current JEVCO 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:

JEVCO 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: __________________________________________

 
 
© J.D. Smith & Associates Insurance Brokers Inc., 1999-2012. All rights reserved.
E. & O. E. Read Disclaimer
Web Site design by interAD Marketing Ltd. 905-780-6473