* Insured First Name #1
* Insured Last Name #1
Date of Birth
Driver's License Number

Your privacy is very important to us. Valley Wide Insurance Services Inc. wants to make sure your personal information remains safe and protected.

This is a consent for communicating by email and sending/receiving your personal information, insurance forms, and if applicable banking information by email. It is important that you understand the following conditions:

• Getting your information by email message may not always be secure. Your email could be broken into and your information could be seen, shared with others, or changed without your permission. We recommend deleting information from your email to reduce the risk to you. 

• Depending on your email provider, information we send to you may be stored outside of Canada.

• If you delete email messages from Valley Wide Insurance Services Inc.,  backup copies could still be on your computer or in cyberspace.
• After your transaction is processed, you will be sent an email with your policy documents. ICBC requires you to respond to that email and tell us if you have accepted your policy terms. You’ll be given options to confirm your acceptance.

* *Required - Full Legal Name

Insured #2 (if a Jointly owned vehicle)

Insured Name #2
Type of Transactions*
Make/Model of Vehicle
Licence Plate #
Expiry Date
Phone Number
- -
Postal Code
Mode of Payment
Preferred Office

Important: By checking the box below, I consent to a Valley-Wide Insurance Advisor accessing my ICBC account for Policy details. *

Important: By checking below, I agree and understand that my insurance is not renewed and my coverage will not take effect until a licensed insurance representative has contacted me an confirmed that coverage is bound.