ICBC REQUEST FORM

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

By checking the box below, you are consenting to receie your personal information, insurance forms and,if applicable, banking information by email ?

Insured #2 (if a Jointly owned vehicle)

Insured Name #2
Type of Tranactions*
Make/Model of Vehicle
Licence Plate #
Expiry Date
Phone Number
- -
Email
City
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.