Referral Form

Because we specialize in the High Risk Insurance market, many of our clients come to us by way of referral. Please fill out the info below and we will call you immediately. (Open to residents of Ontario, Canada only)
Type of insurance
I was referred by
Your name
Postal code
Phone number
Email address

I agree to receive emails from High Risk Insurance Quote Line

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By clicking submit you are authorizing M. Edward Powell Insurance Brokers Ltd. to contact you via email in accordance with all local and Federal electronic communications legislation. Such correspondence may occur now and into the future regarding this inquiry.