Note: Blue labels indicate required entry fields.

First Name:

Last Name:

Street Address:

City:

Province
Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario PEI Quebec Saskatchewan

Postal Code:

Fax Number:

Email Address:

How did you hear about us?
Brochure Current Policyholder Direct Mail Campaign Employer Email Broadcast Employer Fax Broadcast Employer Intranet Site Employer Seminar Former Policyholder Internet Newsletter/Trade Magazine Referred by Insurance Company Referred by an MMC Company Referred by a PCS Policyholder Yellow Pages Other

Employer Name or Association:

Do you currently have an insurance policy with PCS? No Yes

Automobile Expiry Date:

Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2012 2013 2014

Please note that automobile insurance is not available in provinces where government automobile plans exist.

Residential Expiry Date:

Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2012 2013 2014

Additional comments or questions:

PRIVACY: Marsh believes strongly in protecting your privacy and the confidentiality of your Personal Information. We acknowledge that you may have privacy and security concerns with respect to the information we collect, use and disclose to third parties for the purpose of allowing us to provide and offer our products and services to you. In order to comply with privacy legislation, we have developed a Privacy Policy which is available at www.marsh.ca. By submitting the above information you are acknowledging that you have read the Privacy Policy and that you consent to the collection, use, disclosure and retention of your Personal Information as set out in the Privacy Policy.