Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Insurance Expiry Date *

MM

DD

YYYY

Terms of Service *

Your privacy is very important to us. We want 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 John Fleming Auto Insurance Agency, 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.

Yes, I consent.

No, I do not consent.

Digital Transacting *

Do you consent to receiving personal information, insurance forms and banking information over email and/or text messaging?

Yes, I consent.

No, I do not consent.

Closing Consent *

I understand that, after my transaction is processed, I will be sent an email with my policy documents. I also understand that I am required to respond to that email confirming that I have recieved the documents, and that I have consented to the transaction.

Yes, I understand.

No, I do not understand.